Gonal-f — United Healthcare

Ovarian Stimulation

Preferred products

Patient meets coverage criteria in section A
Used alone or with intrauterine insemination (IUI)
For diminishing ovarian reserve not responding to clomiphene or letrozole OR unilateral tubal disease with no evidence of compromise on patent side when ≥2 cycles of oral agents have failed to yield dominant follicle on patent side
Dose ≤150 IU/day for no more than 14 days per cycle
Not used in any of the following: unexplained infertility, endometriosis, bilateral tubal factor infertility, unilateral tubal compromise (isthmic, ampullary, fimbrial, peri-tubal, loculated spill, dilatation, phimosis, occlusion), recurrent pregnancy loss, isolated male factor infertility, failure to respond to ovarian stimulation (no follicles ≥15 mm at 150 IU/day), estradiol <100 pg/ml/follicle ≥15 mm, ≥4 follicles ≥15 mm from previous gonadotropin cycle despite dose adjustment, following failed ART cycles due to poor ovarian response or poor-quality oocytes/embryos, dose >150 IU/day, duration >14 days, beyond 3 cycles OR used for fertility preservation prior to gonadotoxic therapy as part of ART

3 months