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Follistim AQ — Highmark

infertility

Preferred products

  • Follistim AQ

Initial criteria

  • Member meets one of the following: (a) Female using the product for infertility AND if using as part of ART treatment program, has the associated ART/IVF medical benefit OR (b) Male with diagnosis of primary or secondary hypogonadotropic hypogonadism AND infertility not caused by primary testicular failure
  • If member does not have the NSF formulary and request is for Gonal-f, member has experienced therapeutic failure or intolerance to plan-preferred Follistim AQ