Lupron Depot-Ped — Highmark

Initial criteria

• Diagnosis of central precocious puberty
• Onset of secondary sexual characteristics before age 8 if female OR before age 9 if male OR prescriber attests therapy is medically necessary if older
• Elevated basal luteinizing hormone (LH) level > 0.2 - 0.3 IU/L OR elevated leuprolide-stimulated LH level > 3.3 – 5.0 IU/L
• Advancement of bone age beyond chronological age

Reauthorization criteria

• Positive clinical response defined as one of the following: pre-pubertal slowing or decline, normalization of follicle stimulating hormone (FSH), normalization of LH, normalization of bone age, normalization of estradiol level, or normalization of testosterone level

Approval duration

12 months