Gonal-F — CareFirst (Caremark)
Ovulation induction or assisted reproductive technology (ART) in anovulatory or ovulatory infertile women
Initial criteria
- For ovulation induction or ART: Member has completed three or more previous cycles of clomiphene or letrozole OR Member has a risk factor for poor ovarian response to clomiphene or letrozole OR Member has a contraindication or exclusion to clomiphene or letrozole OR Member is age ≥ 37 years
- For hypogonadotropic hypogonadism: Member has a low pretreatment testosterone level AND Member has low or low‑to‑normal follicle stimulating hormone (FSH) or luteinizing hormone (LH) levels
Reauthorization criteria
- Continuation of therapy requires meeting all requirements in the coverage criteria section
Approval duration
12 months