Gonal-f — Highmark
primary or secondary hypogonadotropic hypogonadism (excluding primary testicular failure)
Preferred products
- Follistim AQ
Initial criteria
- One of the following: (a) Member is female AND is using the product for infertility AND if used as part of ART treatment program, member has associated ART/IVF medical benefit OR (b) Member is male AND has a diagnosis of primary or secondary hypogonadotropic hypogonadism AND infertility is 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 Follistim AQ