Gonadotropin-Releasing Hormone Antagonists (Infertility Agents)
Indications for Prior Authorization
Cetrotide (cetrorelix), Generic cetrorelix
-
For diagnosis of Controlled ovarian stimulation
Indicated for the inhibition of premature LH surges in women undergoing controlled ovarian stimulation. -
For diagnosis of Fertility Preservation with Assisted Reproductive Technology (ART)
May be used in assisted reproductive technology (ART) for fertility preservation. [5,6]
Fyremadel, Generic ganirelix
-
For diagnosis of Controlled ovarian stimulation
Indicated for the inhibition of premature LH surges in women undergoing controlled ovarian hyperstimulation. -
For diagnosis of Fertility Preservation with Assisted Reproductive Technology (ART)
May be used in assisted reproductive technology (ART) for fertility preservation. [5,6]
Criteria
Brand Fyremadel*, Generic ganirelix*, Generic cetrorelix*
*Please consult client-specific resources to confirm whether benefit exclusions should be reviewed for medical necessity.
Prior Authorization
Length of Approval: 6 Month(s)
For diagnosis of Infertility
- Diagnosis of infertility AND
- For the development of multiple follicles (ovarian stimulation) AND
- Will be used in conjunction only with assisted reproductive technology (ART)
Brand 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)
For diagnosis of Infertility
- 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
- Fyremadel
Brand Fyremadel, Generic ganirelix, Brand Cetrotide, Generic cetrorelix
*Please consult client-specific resources to confirm whether benefit exclusions should be reviewed for medical necessity.
Prior Authorization
Length of Approval: 2 months (or per plan benefit design)
For diagnosis of Fertility Preservation with Assisted Reproductive Technology (ART)* (off-label)
- Used for fertility preservation AND
- Patient will undergo gonadotoxic therapy (e.g., chemotherapy, surgery, prolonged hormonal ovarian suppression, radiation therapy) AND
- Will be used as part of an assisted reproductive technology procedure (e.g., oocyte or embryo cryopreservation) AND
- Prescribed by or in consultation with a reproductive endocrinologist
P & T Revisions
2025-09-18, 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. Lupin Pharmaceuticals, Inc. Naples, FL. March 2025.
- Fyremadel Prescribing Information. Ferring Pharmaceuticals Inc. Parsippany, NJ. January 2025.
- Cetrorelix Prescribing Information. Apotex Corp. Weston, Florida. June 2025.
- Practice Committee of the American Society for Reproductive Medicine. Fertility preservation in patients undergoing gonadotoxic therapy or gonadectomy: a committee opinion. Fertility and Sterility. 2019 Dec;112(6):1022-1033.
- Su HI, Lacchetti C, Letourneau J, et al. Fertility preservation in people with cancer: ASCO guideline update. J Clin Oncol. 2025;43(12):1488-1515.
Revision History
- 2025-09-18: Added generic cetrorelix to guideline with criteria to mirror generic ganirelix. Added off-label criteria for fertility preservation. Background updates.
- 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