CurrentHawaii Medical Service Association (HMSA)Policy N/A

Gonal-F (follitropin alfa) prior authorization request

Form and criteria for requesting prior authorization from CVS Caremark for Gonal-F (follitropin alfa) under HMSA prescription benefit; used by prescribing providers to obtain coverage determination and document clinical justification.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyGonal-F (follitropin alfa) prior authorization request

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete and fax the Gonal-F prior authorization form to CVS Caremark at 1-866-237-5512.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-866-237-5512authorization submission fax

1-808-254-4414authorization questions

1-800-237-2767CaremarkConnect

Follistim AQpreferred product

required if applicableIVF approval

Authorization Criteria for Gonal-F

Authorization criteria for Gonal-F

Coverage is contingent on completing the prior authorization form and meeting one of the following scenarios:

ANY of the following

ALL of the following
- Member can be switched to Follistim AQ — no authorization required
  Follistim AQ is the plan-preferred follitropin product and does not require authorization
ALL of the following
- Member has documented contraindication to Follistim AQ or any of its components — attach documentation and proceed with authorization for Gonal‑F
  Attach documentation describing the contraindication as requested on the form
ALL of the following

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyGonal-F (follitropin alfa) prior authorization request

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete and fax the Gonal-F prior authorization form to CVS Caremark at 1-866-237-5512.

SourceLink

On This Page

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Member has history of intolerance or confirmed adverse event with Follistim AQ — attach documentation and proceed with authorization for Gonal‑F
Attach documentation describing the intolerance or adverse event as requested on the form

ALL of the following

Provide ICD‑10 diagnosis, prescribed dose of Gonal‑F, administration site, and patient/provider demographics on the prior authorization form
Form asks for ICD‑10 code, prescribed dose, dispensing/administration site, and prescriber information

ALL of the following

If use is for IVF, indicate whether HMSA IVF approval has been obtained and attach the HMSA IVF approval form if available
Form requests attachment of HMSA IVF approval form when IVF procedure is approved by HMSA

Approvals may be subject to dosing limits per FDA‑approved labeling, accepted compendia, and evidence‑based practice guidelines

Dosing limits subject to FDA labeling and evidence‑based guidelines

Diagnosis, Dosing, and Coding Notes

Diagnosis codingICD-10

ICD-10 code to be provided by prescriber

Dosing limits and dose documentation

Dosing limits policyApprovals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines.

Prescribed dose requiredAuthorization form asks: 'What is the prescribed dose of Gonal-F?' — prescriber must provide the dose on the form.

Documentation availabilityPrescriber attests that supporting documentation is available for review by CVS Caremark or the benefit plan sponsor.

Submission, Documentation, and Provider Requirements

Prior Authorization

Submission and contact instructions

Complete the Gonal‑F prior authorization form and fax it to CVS Caremark at 1-866-237-5512. For authorization questions call CVS Caremark at 1-808-254-4414; for eligibility/cost/delivery questions contact CaremarkConnect at 1-800-237-2767.

Step Therapy

Step therapy / preferred product

If the member can be switched to the plan-preferred product Follistim AQ, no authorization is required. If the member has a contraindication or intolerance to Follistim AQ, attach documentation describing the contraindication or adverse event and continue the authorization process for Gonal‑F.

If Yes (can be switched): no further questions; Follistim AQ does not require authorization.
If contraindication or intolerance: attach supporting documentation and proceed with authorization.

Documentation Required

Documentation requirement for IVF

If the intended use is for IVF, indicate whether HMSA IVF approval has been obtained and attach a copy of the HMSA IVF approval form if available.

Documentation Required

Clinical information required

Provide the ICD-10 diagnosis code, the prescribed dose of Gonal‑F, the administration site, and attach documentation for any contraindications or prior adverse events when applicable.

Include ICD-10 code on the form (question #3).
Document prescribed dose of Gonal‑F (question #7) and administration/dispensing site (questions #1–2).
Attach documentation describing contraindications or confirmed adverse events to Follistim AQ when indicated (questions #5–6).

Product Definitions

Follistim AQ (plan-preferred follitropin)

Preferred productFollistim AQ is the plan-preferred follitropin product and does not require authorization.

Switch to preferred productIf the member can be switched to Follistim AQ, no further questions are required on the authorization form.

Contraindication documentationIf the member has a contraindication to Follistim AQ, attach documentation describing the contraindication and proceed with authorization for Gonal‑F.

Intolerance/adverse event documentationIf the member has a history of intolerance or a confirmed adverse event with Follistim AQ, attach documentation describing the intolerance or adverse event.