CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

GnRH antagonists (cetrorelix, ganirelix) for inhibition of premature LH surges

Defines coverage for cetrorelix- and ganirelix-containing products (Cetrotide, Fyremadel, ganirelix branded generic) to inhibit premature luteinizing hormone (LH) surges in women undergoing controlled ovarian stimulation or assisted reproductive technology (ART), with requirements for authorization and continuation.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGnRH antagonists (cetrorelix, ganirelix) for inhibition of premature LH surges

Policy CodePolicy N/A

Change TypeClarified (medical benefit alignment)

Effective Date

Next Review Date

Key ActionProviders must obtain authorization for use of cetrorelix or ganirelix for inhibition of premature LH surges; authorization may be granted up to 12 months when criteria are met.

POLICY UPDATE CHANGES

No material clinical or coverage changes were made in this update.

1Covered Indication (primary)

0Non‑covered indications (examples)

Coverage Summary

Defines coverage for cetrorelix- and ganirelix-containing products (Cetrotide, Fyremadel, ganirelix branded generic) to inhibit premature luteinizing hormone (LH) surges in women undergoing controlled ovarian stimulation or assisted reproductive technology (ART). Coverage stance: covered_with_criteria. Members are covered when the medication is one of the referenced products and the indication is inhibition of premature LH surges during controlled ovarian stimulation/ovulation induction/ART, provided the member has no therapy exclusions and any required documentation for medical benefit alignment is supplied.

Covered Indication / Initial Authorization

Covered when ALL of the following are met:

ALL of the following

Medication requested is cetrorelix (Cetrotide) or ganirelix (Fyremadel or branded generic)
Indication is inhibition of premature luteinizing hormone (LH) surges in women undergoing controlled ovarian stimulation, ovulation induction, or assisted reproductive technology (ART)
Member has no exclusions to the prescribed therapy
When applicable, a medical authorization number and confirmation of the approved procedure(s) are provided for members whose procedure was approved under the member's medical benefit plan (medical benefit alignment)
Some plans may opt out of medical benefit alignment: those members must meet standard criteria

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Not Covered / Investigational

Not covered when ANY of the following apply:

ANY of the following

Use for indications other than inhibition of premature LH surges (i.e., all non–FDA-approved indications and non-compendial uses)
All other indications are considered experimental/investigational and not medically necessary

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Continuation Therapy Criteria

Continuation of Therapy

All members (including new members) requesting authorization for continuation of therapy must meet all initial authorization criteria

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Continuation authorization: Authorization may be granted for up to 12 months for inhibition of premature LH surges in members undergoing ovulation induction or ART. For continuation of therapy (including new members), all initial authorization criteria must continue to be met.

Provider Actions / Prior Authorization

Prior Authorization

Authorization required

Providers must obtain authorization for use of cetrorelix or ganirelix for inhibition of premature LH surges; authorization may be granted for up to 12 months when criteria are met.

Authorization may be granted for up to 12 months when criteria are met.

Documentation Required

Medical benefit alignment documentation

If the drug is requested for a procedure approved under the member's medical benefit plan, provide the medical authorization number and confirmation of the approved procedure(s) so Specialty Guideline Management coverage review will be bypassed (unless the plan has opted out of medical benefit alignment).

Documentation Required

Continuation documentation

For continuation of therapy (including new members), submit documentation demonstrating that all initial authorization criteria continue to be met.

Clinical Evidence & Background

Cetrorelix and ganirelix are gonadotropin‑releasing hormone (GnRH) antagonists indicated to inhibit premature luteinizing hormone (LH) surges during controlled ovarian stimulation. FDA‑approved products include Cetrotide (cetrorelix) and Fyremadel (ganirelix).

Package inserts referenced: Cetrotide (Dec 2023/Mar 2024), Fyremadel (Oct 2023), Ganirelix (Feb 2024).

Medical benefit alignment: Process where Specialty Guideline Management coverage review is bypassed if the drug is requested as part of a procedure already approved under the member's medical benefit plan; a medical authorization number and confirmation of the approved procedure(s) are required, though some plans may opt out of this alignment and those members must meet the standard criteria.

Revision History

clarifiedLatest

Specialty Guideline Management coverage review will be bypassed for drugs requested for procedures approved under a member's medical benefit plan; a medical authorization number and confirmation of the approved procedure(s) are required. Note that some plans may opt out of medical benefit alignment; members under those plans must meet the standard criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGnRH antagonists (cetrorelix, ganirelix) for inhibition of premature LH surges

Policy CodePolicy N/A

Change TypeClarified (medical benefit alignment)

Effective Date

Next Review Date

Key ActionProviders must obtain authorization for use of cetrorelix or ganirelix for inhibition of premature LH surges; authorization may be granted up to 12 months when criteria are met.

On This Page

Cetrotide	cetrorelix acetate (brand)
Fyremadel	ganirelix acetate (brand)
ganirelix (branded generic)	ganirelix acetate branded generic
cetrorelix (generic)	cetrorelix acetate generic

OpenPayer

GnRH antagonists (cetrorelix, ganirelix) for inhibition of premature LH surges

Coverage Summary

Continuation Therapy Criteria

Applicable Codes

Provider Actions / Prior Authorization

Clinical Evidence & Background

Revision History