Gonal-F — CareFirst (Caremark)
Hypogonadotropic hypogonadism (male)
Initial criteria
- Follicle Stimulation: Member is undergoing ovulation induction or ART AND meets any of the following: (a) Member has completed three or more previous cycles of clomiphene or letrozole; OR (b) Member has a risk factor for poor ovarian response to clomiphene or letrozole; OR (c) Member has a contraindication or exclusion to clomiphene or letrozole; OR (d) Member is age ≥ 37 years.
- Hypogonadotropic Hypogonadism: Member has a low pretreatment testosterone level AND low or low-to-normal follicle stimulating hormone (FSH) or luteinizing hormone (LH) levels.
Reauthorization criteria
- All members (including new members) requesting authorization for continuation of therapy must meet all requirements in the coverage criteria section.
Approval duration
12 months