Prior authorization required

Prior authorization is required through Optum Fertility Solutions. When criteria are met, authorizations will be issued for 3 months for ovulation induction, ovarian stimulation (including fertility preservation), assisted reproductive technology (ART), and male hypogonadotropic hypogonadism.

Document ovarian reserve and response

Document prognosis for conception (≥ 5%), provide at least two ovarian reserve markers obtained within the previous 6 months (examples: FSH, AMH, antral follicle count, or documented embryo aneuploidy risk), and when applicable include evidence of prior ovarian response to stimulation (e.g., follicle sizes/counts such as one follicle ≥ 15 mm for IUI or minimum one follicle ≥ 15 mm for ART).

• Prognosis for conception ≥ 5%
• At least two ovarian reserve markers within previous 6 months: FSH, AMH, antral follicle count, or embryo aneuploidy risk
• Evidence of prior ovarian response when applicable (follicle sizes/counts; e.g., ≥ 15 mm thresholds for IUI/ART)

Step requirement for Gonal-f

For requests for Gonal-f or Gonal-f RFF, documentation must show prior failure, contraindication, or intolerance to Follistim AQ unless the patient has hypothalamic amenorrhea (in which case the step requirement is bypassed).

• Require documentation of failure, contraindication, or intolerance to Follistim AQ for Gonal-f/Gonal-f RFF requests
• Hypothalamic amenorrhea diagnoses may bypass the step requirement

Denial if excluded situation

Claims will be denied when use falls into excluded situations listed in the criteria. Common denial triggers include doses or durations that exceed program thresholds (e.g., >225 IU/day for ovulation induction, >150 IU/day for ovarian stimulation, >450 IU/day or >14 days for ART), indications explicitly listed as not applicable (such as unexplained infertility or certain tubal/endometriosis scenarios depending on pathway), and prior ART failure scenarios noted in the policy.

• Doses/durations above specified thresholds (examples: >225 IU/day for ovulation induction; >150 IU/day for ovarian stimulation; >450 IU/day or duration >14 days for ART)
• Infertility etiologies or situations listed as not applicable for a given pathway (e.g., unexplained infertility, certain tubal factors, endometriosis per path-specific exclusions)
• Prior ART failure scenarios and failures to respond to prior stimulation as listed in the criteria

Supply limits and automated approvals may apply

Supply limits and automated approval logic may apply. UnitedHealthcare/Optum Fertility Solutions may approve initial or reauthorization based on prior claim or medication history, diagnosis codes (ICD-10), and/or automated claim logic per program rules.

• Supply limits may be in place
• Automated approvals can use prior medication/claim history and ICD-10 diagnosis codes