Follistim AQ (follitropin beta)
Pharmacy benefit prior authorization policy for Follistim AQ (follitropin beta), Gonal-F (follitropin alfa), and Gonal-F RFF for ovulation induction/follicle stimulation as part of ART and treatment of hypogonadotropic hypogonadism. Applies to commercial/exchange members; product designated specialty and must be filled at contracted specialty pharmacy.
Removed Bravelle as product is no longer available and added Gonal-F RFF as a preferred agent along with Gonal-F.
Coverage Summary
This policy is a pharmacy benefit prior authorization for Follistim AQ (follitropin beta), Gonal-F (follitropin alfa), and Gonal-F RFF (follitropin alfa) for ovulation induction/follicle stimulation as part of assisted reproductive technology (ART) programs and for treatment of hypogonadotropic hypogonadism. It applies to Commercial/Exchange members. These products are designated specialty and must be filled at a contracted specialty pharmacy.