Crinone 8% — Highmark

Preferred products

• Endometrin

Initial criteria

• The member is female AND is using the product for infertility AND is using Crinone 8% as part of an ART treatment program AND has the associated ART/IVF benefit AND (if the member does not have the NSF formulary, has experienced therapeutic failure or intolerance to plan-preferred Endometrin)
• OR The member is female AND has a diagnosis of secondary amenorrhea

Approval duration

3 months for IVF technique; 6 months for other ART techniques, ovulation induction, hypogonadotropic hypogonadism, and fertility preservation; 1 month for secondary amenorrhea