Trelstar
Generic: triptorelin
11.25 MG — Suspension
Gonadotropin Releasing Hormone Receptor Agonist
Also known as:
triptorelin
Trelstar Mixject Intramuscular Suspension Reconstituted
Triptorelin
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Coverage by Insurer
Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Ambetter (Centene)
29 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Complete Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Everyday Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Elite Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Enhanced Asthma/COPD Care Silver with $0 Drug Options | Tier 5 - Specialty | ✓ | — | — | PA |
| Everyday Bronze | Tier 5 - Specialty | ✓ | — | — | PA |
| Elite Bronze | Tier 5 - Specialty | ✓ | — | — | PA |
| Complete Gold | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Silver + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Expanded Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | — | PA |
| Clear Silver with $0 Insulin Options | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Expanded Bronze | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Silver | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Gold | Tier 5 - Specialty | ✓ | — | — | PA |
| Everyday Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Elite Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Focused Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Complete Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Expanded Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
| Standard Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | — | PA |
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 5 - Specialty | ✓ | — | — | PA |
Medicare Part D
63 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| PruittHealth Premier (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 1 per 168 days | QL |
| NHC Advantage (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 1 per 168 days | QL |
| Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 1 per 168 days | QL |
| Liberty Medicare Dual Plan (HMO D-SNP) | Tier 1 - Preferred Generic | — | — | ✓ 1 per 168 days | QL |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | — | PA |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 1 per 168 days | PA | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 1 per 168 days | PA | QL |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | ✓ | — | ✓ 1 per 168 days | PA | QL |
| Humana Dual Select H6622-027 (HMO-POS D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring True Choice (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring TotalCare (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring TotalCare Plus (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred Select (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred Savings (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthSpring Preferred Plus (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Troy Medicare (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H1036-137 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H1036-233 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Dual Select H1036-307 (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus Giveback H1036-318 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H1036-335 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice Giveback H5216-017 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5216-211 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Full Access H5525-034 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice Giveback H5525-035 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice SNP-DE H5525-036 (PPO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5525-049 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5525-050 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5525-070 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Dual Select H5525-072 (PPO D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HumanaChoice H5525-083 (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H6622-025 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H6622-026 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H6622-057 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H6622-060 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus H6622-061 (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Choice H8145-004 (PFFS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Humana Gold Plus - Diabetes and Heart (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Senior Care (HMO I-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 1 per 168 days | QL |
| Liberty Medicare Advantage (HMO C-SNP) | Tier 4 - Non-Preferred | — | — | ✓ 1 per 168 days | QL |
| Blue Medicare PPO Enhanced (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Blue Medicare Essential Plus (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Blue Medicare Enhanced (HMO-POS) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Blue Medicare Choice (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Blue Medicare Essential (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Experience Health Medicare Advantage (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Healthy Blue + Medicare (HMO-POS D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health Platinum (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health smartHMO (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health Platinum Select (HMO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Alignment Health AVA (PPO) | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| HealthTeam Advantage Plan I (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 1 per 168 days | PA | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 1 per 168 days | PA | QL |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 4 - Non-Preferred | ✓ | — | ✓ 1 per 168 days | PA | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 4 - Non-Preferred | ✓ | — | ✓ 1 per 168 days | PA | QL |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
|
AIAN Cost Share
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
AIAN Cost Share | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Chronic Care CKM | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Diabetes | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Chronic Care CKM | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Elite Saver Plus | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700 | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic 4700
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Elite + PCP Saver Plus
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple PCP Saver
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Secure | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Simple Diabetes
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Elite Saver Plus
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Bronze Classic Standard | with Atrium Health
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Gold Classic Standard
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
|
Silver Classic Standard
via Triptodur |
Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |