Supprelin LA® (histrelin acetate implant)

Authorization forms

Traditional, Optimized & Medicaid (09/2018)

No prior authorization required for Medicare

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J9926

Benefit: Medical

Notes: Implant for treatment of central precocious puberty