leuprolide acetate injection solution — CareFirst (Caremark)

Initial criteria

• Diagnosis of CPP has been confirmed by a pubertal response to a gonadotropin releasing hormone (GnRH) agonist test or a pubertal level of a third-generation luteinizing hormone (LH) assay
• Assessment of bone age versus chronological age supports the diagnosis of CPP
• Member is a female and was less than 8 years of age at onset of secondary sexual characteristics OR member is a male and was less than 9 years of age at onset of secondary sexual characteristics
• Pathologic cause of CPP has been assessed (e.g., imaging screening for intracranial tumors, genetic testing for familial CPP)

Reauthorization criteria

• Member is currently receiving the requested medication through a paid pharmacy or medical benefit
• Member is a female less than 12 years of age OR a male less than 13 years of age
• Member is not experiencing treatment failure (e.g., clinical pubertal progression, lack of growth deceleration, continued excessive bone age advancement)

Approval duration

12 months