Ganirelix (brand and generic) — Cigna

Preferred products

• Cetrotide (brand and generic)
• Fyremadel

Initial criteria

• If patient’s benefit includes infertility coverage, approve for 1 year if patient has tried one of cetrorelix acetate subcutaneous injection (Cetrotide, generics) or Fyremadel.
• If patient’s benefit does NOT include infertility coverage and benefit exclusion overrides ARE utilized, approve for 1 year if patient meets BOTH of the following criteria (A and B): A) The patient meets the standard Infertility – Gonadotropin-Releasing Hormone Antagonists Benefit Exclusion Overrides Policy criteria; AND B) The patient has tried one of cetrorelix acetate subcutaneous injection (Cetrotide, generics) or Fyremadel.

Approval duration

1 year