Gonal-f RFF — United Healthcare
Male Hypogonadotropic Hypogonadism
Preferred products
- Follistim AQ
Initial criteria
- Prognosis for conception must be ≥ 5%
- Adequate ovarian reserve indicated by at least two of the following within previous 6 months: FSH level < 15 mIU/ml, AMH level > 0.2 ng/ml, Antral follicle count > 3, Risk for aneuploidy for all embryos ≤ 85%
- Evidence of adequate ovarian response to stimulation if previously monitored, medicated-stimulated infertility treatment within 6 months, e.g., one follicle ≥ 15 mm diameter for IUI or at least one follicle ≥ 15 mm for ART
- If request is for Gonal-f or Gonal-f RFF, must have history of failure, contraindication, or intolerance to Follistim AQ
- Used for one of the following: Ovulation Induction, Ovarian Stimulation, Assisted Reproductive Technology
Approval duration
3 months