Gonal-f — Highmark
primary or secondary hypogonadotropic hypogonadism
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