Gonal-f — United Healthcare
Ovulation Induction
Preferred products
- Follistim AQ
Initial criteria
- Patient meets coverage criteria in section A
- Failure to ovulate with Clomid (clomiphene citrate) or Femara (letrozole) OR patient diagnosed with hypothalamic amenorrhea
- One of the following exists: Anovulation OR Oligo-ovulation OR both of the following: Amenorrhea AND other causative factors (e.g. thyroid disease, hyperprolactinemia) excluded or treated
- Dose does not exceed 225 IU/day AND duration of therapy does not exceed 14 days per cycle unless hypothalamic amenorrhea
- Not used in any of the following: beyond 6th gonadotropin induced ovulatory cycle, ≥4 follicles ≥15 mm from previous gonadotropin cycle despite dosage adjustment, used alone in unexplained infertility, failure to respond to ovulation induction at 225 IU/day, used to correct thin endometrial lining, estradiol <100 pg/ml/follicle ≥15 mm, dose >225 IU/day, duration >14 days (except hypothalamic amenorrhea)
Approval duration
3 months