Follistim AQ — Cigna
Ovulation induction
Preferred products
- Clomid
- Clomiphene citrate
- Gonal-f
- Gonal-f RFF
- Gonal-f RFF Redi-ject
Initial criteria
- Approve for 1 year if the patient has tried at least one of Gonal-f, Gonal-f RFF, or Gonal-f RFF Redi-ject.
- For a patient who has not tried at least one of the Step 2 Preferred follitropin products: offer to review for Gonal-f, Gonal-f RFF, or Gonal-f RFF Redi-ject.
- Patient already started on a cycle of treatment with Follistim AQ for the induction of spermatogenesis in patients with primary or secondary hypogonadism: approve for 1 year.
- Patient already started on a cycle of treatment with Follistim AQ: approve for the duration needed to complete the current cycle.
Approval duration
1 year or duration of current cycle