Gonal-f (follitropin alfa) — United Healthcare

Ovarian stimulation

Initial criteria

For Ovarian Stimulation: ONE of the following:
A) ALL of the following:
• Diagnosis of infertility
AND • For the development of multiple follicles (controlled ovarian stimulation)
AND • ONE of the following:
(a) BOTH of the following:
i. ONE of the following exists: Diminished ovarian reserve OR Endometriosis OR Male factor infertility OR Tubal factor infertility OR Unexplained infertility OR Uterine factor infertility OR Ovulatory dysfunction OR Recurrent pregnancy loss OR Failure to achieve conception with other treatment modalities
AND ii. Will be used in conjunction with assisted reproductive technology (ART)
OR (b) BOTH of the following:
i. ONE of the following exists: Diminished ovarian reserve OR Mild to moderate male factor infertility OR Minimal to mild endometriosis OR Unilateral tubal factor infertility OR Unexplained infertility
AND ii. Will be used in conjunction with intrauterine insemination (IUI)
OR B) ALL of the following (Fertility Preservation):
• 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

2 months