CurrentColorado Rocky Mountain Health PlansPolicy N/A

Cetrotide and ganirelix acetate prior authorization

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This policy governs coverage authorization for Cetrotide (cetrorelix acetate) and ganirelix acetate used for ovarian stimulation or fertility preservation. It applies to members whose benefit plans include these pharmacy services, subject to plan exclusions, mandates, and other utilization management rules.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCetrotide and ganirelix acetate prior authorization

Policy CodePolicy N/A

Change TypeAdministrative and reference update

Effective DateSep 1, 2026

Last ReviewJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization or provide notification for Cetrotide or ganirelix acetate before treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Medications covered

2 monthsAuthorization duration

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CurrentColorado Rocky Mountain Health PlansPolicy N/A

Cetrotide and ganirelix acetate prior authorization

Customize your policy alerts

Sign up for all Colorado Rocky Mountain Health Plans policy alerts

Know when Colorado Rocky Mountain Health Plans releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCetrotide and ganirelix acetate prior authorization

Policy CodePolicy N/A

Change TypeAdministrative and reference update

Effective DateSep 1, 2026

Last ReviewJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization or provide notification for Cetrotide or ganirelix acetate before treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Medications covered

2 monthsAuthorization duration

Coverage Criteria

Initial therapy: ovarian stimulation or fertility preservation

Cetrotide or ganirelix acetate will be approved when either of the following criteria pathways is met.

Qualifying indication

Ovarian stimulation
- Infertility diagnosis: Diagnosis of infertility
- Qualifying infertility condition or history
  - Unexplained infertility
  - Endometriosis
  - Male factor infertility
  - Tubal factor infertility
  - Diminished ovarian reserve
  - Uterine factor infertility
  - Ovulatory dysfunction
  - Recurrent pregnancy loss
  - Failure to achieve conception with other treatment modalities
- Ovarian stimulation use: For the development of one or more follicles (ovarian stimulation).
- ART use: Will be used in conjunction only with assisted reproductive technology (ART).
Fertility preservation
- Fertility preservation use: Used for fertility preservation.
- Gonadotoxic therapy: The individual will undergo gonadotoxic therapy, such as exposure to cytotoxic agents, invasive surgery, prolonged hormonal ovarian suppression, or radiation therapy.
- ART procedure: Will be used as part of an assisted reproductive technology procedure, such as in vitro fertilization.

Infertility is typically excluded from coverage. Review the member’s specific benefit plan to determine whether an infertility exclusion applies before assessing coverage for Cetrotide (cetrorelix acetate) or ganirelix acetate. State mandates, federal regulatory requirements, and other plan-specific coverage provisions may also affect the determination.

Authorization and Denial Considerations

Prior Authorization

Prior Authorization Required

Prior authorization is required for Cetrotide (cetrorelix acetate) or ganirelix acetate. When authorized, approval will be issued for 2 months.

Applies to Cetrotide (cetrorelix acetate) and ganirelix acetate.
Authorization duration: 2 months.

Denial Risk

Infertility Benefit Exclusion Risk

Infertility is typically excluded from coverage under the member’s plan. Coverage may be denied when the applicable plan-specific infertility exclusion applies; refer to the member’s plan details to determine exclusion status.

State mandates, federal regulatory requirements, and member-specific benefit coverage may affect coverage.
Other policies and utilization management programs may also apply.

Clinical Background

Cetrotide (cetrorelix acetate) and ganirelix acetate are synthetic decapeptides with gonadotropin-releasing hormone antagonist activity. They inhibit premature luteinizing hormone surges in women undergoing ovarian stimulation and are used in conjunction with assisted reproductive technology or for fertility preservation before gonadotoxic therapy.