Follistim AQ — Medica
assisted reproductive technology (ART) programs
Preferred products
- Clomid
- Clomiphene citrate
- Gonal-f
- Gonal-f RFF
- Gonal-f RFF Redi-ject
Initial criteria
- Patient's benefit includes infertility coverage
- Patient has tried Preferred Products (Step 1 and Step 2) prior to approval of a Non-Preferred Product
- Preferred Products defined as Step 1: Clomid, Clomiphene citrate; Step 2: Gonal-f, Gonal-f RFF, Gonal-f RFF Redi-ject
Approval duration
as noted in benefit/program (unspecified)