Menopur — United Healthcare

Preferred products

• Follistim AQ

Initial criteria

• Patient meets coverage criteria in section A
• If used for preparation of endometrial lining, failure to achieve sufficient endometrial thickness >6 mm or trilaminar pattern with conventional methods (estrogen, progesterone)
• Total gonadotropin dose ≤450 IU/day for ≤14 days per cycle
• Not used in any of the following: following failed ART cycles due to poor ovarian response or poor-quality oocytes/embryos, dose >450 IU/day, duration >14 days per cycle

Approval duration

3 months