Cetrotide (cetrorelix acetate) — United Healthcare

Preferred products

• ganirelix acetate (Merck and Co., Inc.)
• ganirelix acetate (Organon Global Inc.)

Initial criteria

• Diagnosis of infertility AND one of the following exists: unexplained infertility OR endometriosis OR male factor infertility OR tubal factor infertility OR diminished ovarian reserve OR uterine factor infertility OR ovulatory dysfunction OR recurrent pregnancy loss OR failure to achieve conception with other treatment modalities AND for the development of one or more follicles (ovarian stimulation) AND will be used in conjunction only with assisted reproductive technology (ART) AND history of failure, contraindication, or intolerance to ganirelix acetate (Merck and Co., Inc. and Organon Global Inc. formulations)
• Used for fertility preservation AND the individual will undergo gonadotoxic therapy (e.g., exposure to cytotoxic agents, invasive surgery, prolonged hormonal ovarian suppression, radiation therapy) AND will be used as part of an assisted reproductive technology (e.g., in vitro fertilization) procedure AND history of failure, contraindication, or intolerance to ganirelix acetate (Merck and Co., Inc. and Organon Global Inc. formulations)

Approval duration

2 months