generic leuprolide — Medical Mutual

Initial criteria

• Member has fertility coverage
• Requested by an appropriate fertility specialist
• The woman does not have evidence of inadequate ovarian reserve from any of the following: abnormal clomiphene citrate challenge test OR elevated day 3 FSH level OR abnormal anti-Mullerian hormone of antral follicle count OR age ≥ 44 years
• Tubal obstruction is ruled out
• An abnormal semen analysis is ruled out
• Ovulatory dysfunction is ruled out
• An inoperable uterine cavity abnormality is ruled out

Reauthorization criteria

• Approve if criteria met

Approval duration

1 year