Gonal-f — Cigna
Planned oocyte or embryo preservation
Preferred products
- Clomid
- Clomiphene citrate
Initial criteria
- Approve for 1 year if the patient meets ONE of the following (i, ii, iii, iv, or v):
- i. Patient has tried Clomid tablets or clomiphene tablets; OR
- ii. Patient has tried letrozole tablets for ovulatory dysfunction; OR
- iii. Patient has previously received and/or is continuing infertility treatment with injectable agents (e.g., patient has tried injectable infertility agents in previous cycles and is re-starting new cycle of treatments); OR
- iv. Patient has causes of infertility other than ovulatory dysfunction OR the product is being used for planned oocyte or embryo preservation; OR
- v. The medication is used for the induction of spermatogenesis in a patient with primary or secondary hypogonadism; OR
- Patient already started on a cycle of treatment with a Gonal-f product: approve for the duration needed to complete the current cycle.
Approval duration
1 year or duration of current cycle