Trelstar — Medica
Prostate cancer
Preferred products
- Eligard
- Lupron Depot
- Lutrate Depot
- Firmagon
Initial criteria
- Approve for 1 year if the patient meets ONE of the following (A or B):
- A) Patient meets BOTH of the following (i and ii):
- i. Patient meets the Trelstar criteria in the standard Oncology (Injectable) – Gonadotropin-Releasing Hormone Analogs Prior Authorization Policy; AND
- ii. Patient meets ONE of the following (a or b):
- a) Patient has tried one of Lutrate Depot, Firmagon, Eligard, or Lupron Depot; OR
- b) Patient has already been started on Trelstar and is continuing therapy.
- B) If the patient has met the standard Oncology (Injectable) – Gonadotropin-Releasing Hormone Analogs Prior Authorization Policy criteria (Ai), but has not met exception criteria (Aii) above for brand Trelstar: approve one of Lutrate Depot, Firmagon, Eligard, or Lupron Depot.
Approval duration
1 year