Menopur (menotropins) — United Healthcare

Initial criteria

• A. Ovarian Stimulation: ALL of the following: (1) Diagnosis of infertility AND (2) For the development of multiple follicles (ovarian stimulation) AND (3) 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 Used for fertility preservation AND will undergo gonadotoxic therapy (e.g., cytotoxic agents, invasive surgery, prolonged hormonal ovarian suppression, radiation therapy) AND Will be used as part of an assisted reproductive technology procedure.
• B. Ovulation Induction (Off-Label): ALL of the following: (a) Diagnosis of ovulatory dysfunction AND (b) ONE of the following exists: Anovulation OR Oligo-ovulation OR Amenorrhea AND (c) Other specific causative factors (e.g., thyroid disease, hyperprolactinemia) have been excluded or treated AND (d) Infertility is not due to primary ovarian failure AND (e) For induction of ovulation.
• C. Male Hypogonadotropic Hypogonadism: ALL of the following: (a) ONE of the following: Diagnosis of male primary hypogonadotropic hypogonadism OR Diagnosis of male secondary hypogonadotropic hypogonadism AND (b) For induction of spermatogenesis AND (c) Infertility is not due to primary testicular failure.

Approval duration

2 months