Menopur (menotropins) — CareFirst (Caremark)
Follicle stimulation as part of assisted reproductive technology (ART)
Initial criteria
- Member is undergoing ovulation induction or assisted reproductive technology (ART)
- AND any of the following are met:
- • Member has completed three or more previous cycles of clomiphene or letrozole
- • Member has a risk factor for poor ovarian response to clomiphene or letrozole
- • Member has a contraindication or exclusion to clomiphene or letrozole
- • Member is age ≥ 37 years
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