Ganirelix — Medica

Preferred products

• Cetrotide (cetrorelix acetate)
• Fyremadel

Initial criteria

• If patient's benefit includes infertility coverage, approve for 1 year if patient has tried one of cetrorelix acetate subcutaneous injection (Cetrotide, generics) or Fyremadel.
• If patient's benefit does NOT include infertility coverage and benefit exclusion overrides ARE utilized, approve for 1 year if BOTH of the following (A and B) are met: A) Patient meets the standard Infertility – Gonadotropin-Releasing Hormone Antagonists Benefit Exclusion Overrides Policy criteria; AND B) Patient has tried one of cetrorelix acetate subcutaneous injection (Cetrotide, generics) or Fyremadel.
• If patient has met exception criterion 2A but has not tried a Preferred Product, approve cetrorelix acetate subcutaneous (Cetrotide) and Fyremadel for 1 year.
• If patient's benefit does NOT include infertility coverage and benefit exclusion overrides are NOT utilized: not reviewable.

Approval duration

1 year