Prior authorization required

Does Simply Healthcare Plans, INC. require prior authorization for Trelstar?

Simply Healthcare Plans, INC. requires prior authorization for Trelstar on every Medicare Part D plan of theirs that covers it.

Every plan from this payer that covers the drug requires authorization before it is dispensed.

By product strength

RxNorm product	Plans covering	Require prior auth	Status
triptorelin 22.5 MG Injection [Trelstar]905057	50 / 50	50	Prior authorization required
triptorelin 3.75 MG Injection [Trelstar]905059	50 / 50	50	Prior authorization required
triptorelin 11.25 MG Injection [Trelstar]905064	50 / 50	50	Prior authorization required

Product names come from RxNorm (U.S. National Library of Medicine).

Plan-by-plan detail — triptorelin 22.5 MG Injection [Trelstar]

Trelstar has 3 products in the corpus; this table is for triptorelin 22.5 MG Injection [Trelstar], the one carried on the most plans. The product table above covers every strength.

Plan	Contract	Tier	Prior auth	Step therapy	Qty limit
Simply Complete (HMO D-SNP)	H5471-064	4	Yes	No	No
Simply Complete (HMO D-SNP)	H5471-066	4	Yes	No	No
Simply Complete (HMO D-SNP)	H5471-072	4	Yes	No	No
Simply Complete (HMO D-SNP)	H5471-076	4	Yes	No	No
Simply Complete (HMO D-SNP)	H5471-082	4	Yes	No	No
Simply Complete (HMO D-SNP)	H5471-084	4	Yes	No	No
Simply Complete (HMO D-SNP)	H5471-111	4	Yes	No	No
Simply Complete Platinum (HMO D-SNP)	H5471-115	4	Yes	No	No
Simply Complete Platinum (HMO D-SNP)	H5471-118	4	Yes	No	No
Simply Complete Platinum (HMO D-SNP)	H5471-121	4	Yes	No	No
Simply Complete Platinum (HMO D-SNP)	H5471-125	4	Yes	No	No
Simply Complete Platinum (HMO D-SNP)	H5471-138	4	Yes	No	No
Simply Complete Platinum (HMO D-SNP)	H5471-140	4	Yes	No	No
Simply Complete Platinum (HMO D-SNP)	H5471-142	4	Yes	No	No
Simply Extra (HMO)	H5471-112	4	Yes	No	No
Simply Extra Platinum (HMO)	H5471-113	4	Yes	No	No
Simply Extra Platinum (HMO)	H5471-117	4	Yes	No	No
Simply Extra Platinum (HMO)	H5471-120	4	Yes	No	No
Simply Extra Platinum (HMO)	H5471-123	4	Yes	No	No
Simply Integrated (HMO D-SNP)	H5471-127	4	Yes	No	No
Simply Integrated (HMO D-SNP)	H5471-128	4	Yes	No	No
Simply Integrated (HMO D-SNP)	H5471-129	4	Yes	No	No
Simply Integrated (HMO D-SNP)	H5471-130	4	Yes	No	No
Simply Integrated (HMO D-SNP)	H5471-131	4	Yes	No	No
Simply Integrated (HMO D-SNP)	H5471-132	4	Yes	No	No
Simply Integrated (HMO D-SNP)	H5471-133	4	Yes	No	No
Simply Integrated Platinum (HMO D-SNP)	H5471-134	4	Yes	No	No
Simply Integrated Platinum (HMO D-SNP)	H5471-135	4	Yes	No	No
Simply Integrated Platinum (HMO D-SNP)	H5471-136	4	Yes	No	No
Simply Integrated Platinum (HMO D-SNP)	H5471-137	4	Yes	No	No
Simply Integrated Platinum (HMO D-SNP)	H5471-139	4	Yes	No	No
Simply Integrated Platinum (HMO D-SNP)	H5471-141	4	Yes	No	No
Simply Integrated Platinum (HMO D-SNP)	H5471-143	4	Yes	No	No
Simply Level (HMO C-SNP)	H5471-069	4	Yes	No	No
Simply Level (HMO C-SNP)	H5471-070	4	Yes	No	No
Simply Level (HMO C-SNP)	H5471-073	4	Yes	No	No
Simply Level (HMO C-SNP)	H5471-075	4	Yes	No	No
Simply Level (HMO C-SNP)	H5471-080	4	Yes	No	No
Simply Level Platinum (HMO C-SNP)	H5471-116	4	Yes	No	No
Simply Level Platinum (HMO C-SNP)	H5471-119	4	Yes	No	No
Simply Level Platinum (HMO C-SNP)	H5471-122	4	Yes	No	No
Simply Level Platinum (HMO C-SNP)	H5471-126	4	Yes	No	No
Simply More (HMO)	H5471-065	4	Yes	No	No
Simply More (HMO)	H5471-071	4	Yes	No	No
Simply More (HMO)	H5471-074	4	Yes	No	No
Simply More (HMO)	H5471-077	4	Yes	No	No
Simply More (HMO)	H5471-078	4	Yes	No	No
Simply More (HMO)	H5471-110	4	Yes	No	No
Simply More Platinum (HMO)	H5471-114	4	Yes	No	No
Simply More Platinum (HMO)	H5471-124	4	Yes	No	No

Source

Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File

Effective: 2026-06-30
Retrieved: 2026-07-19
SHA-256: e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae

We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.

Trelstar at other payers

Or see Trelstar across every payer at once.

Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.