Gonadotropin-Releasing Hormone Antagonists (Infertility Agents)
Indications for Prior Authorization
Cetrotide (cetrorelix)
-
For diagnosis of Controlled ovarian stimulation
Indicated for the inhibition of premature LH surges in women undergoing controlled ovarian stimulation.
Generic ganirelix, Generic Fyremadel
-
For diagnosis of Controlled ovarian stimulation
Indicated for the inhibition of premature LH surges in women undergoing controlled ovarian hyperstimulation.
Criteria
Generic ganirelix*, Generic Fyremadel*
*Please consult client-specific resources to confirm whether benefit exclusions should be reviewed for medical necessity.
Prior Authorization
Length of Approval: 6 Month(s)
- Diagnosis of infertility AND
- For the development of multiple follicles (ovarian stimulation) AND
- Will be used in conjunction only with assisted reproductive technology (ART)
Cetrotide*
*Please consult client-specific resources to confirm whether benefit exclusions should be reviewed for medical necessity.
Prior Authorization
Length of Approval: 6 Month(s)
- Diagnosis of infertility AND
- For the development of multiple follicles (ovarian stimulation) AND
- Will be used in conjunction only with assisted reproductive technology (ART) AND
- Trial and failure, contraindication or intolerance to one of the following:
- Generic Ganirelix
- Generic Fyremadel
P & T Revisions
2024-08-19, 2023-11-01, 2023-08-29, 2023-08-21, 2023-05-05, 2023-01-03, 2022-11-30, 2022-08-22, 2022-02-16, 2021-12-01, 2021-09-10, 2020-07-25, 2020-01-06
References
- Cetrotide Prescribing Information. EMD Serono, Inc. Rockland, MA. June 2024.
- Ganirelix Acetate Prescribing Information. Fresenius Kabi USA, LLC. Lake Zurich, IL. May 2024.
- Fyremadel Prescribing Information. Ferring Pharmaceuticals Inc. Parsippany, NJ. October 2023.
Revision History
- 2024-08-19: 2024 annual review: no criteria changes, background updates.
- 2023-11-01: Removed "PA, NF" from guideline name since NF criteria has been removed
- 2023-08-29: Removed Cetrotide NF criteria and added in trial of generic ganirelix or generic Fyremadel to Cetrotide PA criteria
- 2023-08-21: Removed criterion 2 requiring a cause of infertility (i.e., unexplained infertility, endometriosis, male factor infertility, tubal factor infertility, any other indication for ART). Updated "controlled ovarian hyperstimulation" to "ovarian stimulation" with no change in intent.
- 2023-05-05: Removed generic cetrorelix from guideline.
- 2023-01-03: Minor update
- 2022-11-30: Addition of new generic, cetrorelix acetate
- 2022-08-22: Annual review: no criteria changes.
- 2022-02-16: Program update to add generic Fyremadel to mirror criteria of generic ganirelix.
- 2021-12-01: Program update to include NF criteria for cetrotide
- 2021-09-10: Updated references section.
- 2020-07-25: Annual Review - No changes.
- 2020-01-06: GPI replication update for Generic ganirelix (added 3009004010E520, removed 30090040102020).
HEALTHY LIVING