Establishing Medical Necessity

Establishing medical necessity may be a critical component to initiate a benefit investigation and to provide additional reimbursement support assistance. Payers will likely want to understand the nature of the implant, why it has been recommended and is appropriate for the patient, and the treatment history of the patient.

The following two forms, available for download below, must accompany all request for assistance.

Download Service Request Enrollment Form

Download Patient Authorization Form

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Indication

SUPPRELIN^® LA (histrelin acetate) subcutaneous implant is used for the treatment of children with central precocious puberty (CPP).

Important Safety Information

SUPPRELIN LA should not be used by women who are or may become pregnant, and in patients who are allergic to gonadotropin releasing hormone (GnRH) or GnRH agonist analogs. Safety and effectiveness in children under 2 years of age has not been determined.
SUPPRELIN LA, like other GnRH agonists, may cause a temporary increase in the blood levels of specific hormones associated with the onset of puberty (estrogen in girls and testosterone in both sexes) during the first week of treatment. This increase may temporarily worsen puberty symptoms during the first week, additionally, you may see new symptoms appear during this period. Within the 4 weeks of treatment with SUPPRELIN LA, hormonal suppression generally occurs and the physical signs of puberty should decrease.
Your doctor should monitor the levels of specific hormones associated with puberty progression, 1 month after starting SUPPRELIN LA and then every 6 months thereafter. Every 6-12 months, height and bone age should be also monitored by your doctor.
During the clinical trial testing of SUPPRELIN LA, the most common side effects involved the implant site and included temporary bruising, pain, soreness, redness of the skin and swelling.

Please talk with your doctor for more information or if you have any questions.