Subject: Menopur 1991-A, 1992-A SGM P2023

Drug

MENOPUR  (menotropins for injection)

Policy:

      I.  INDICATIONS

          The indications below including FDA-approved indications and
          compendial uses are considered a covered benefit provided that
          all the approval criteria are met and the member has no
          exclusions to the prescribed therapy.

          FDA-Approved Indication
          Menopur is indicated for development of multiple follicles and
          pregnancy in ovulatory women as part of an assisted
          reproductive technology (ART) cycle.

          All other indications are considered experimental/investigational
          and not medically necessary.


    II.  MEDICAL BENEFIT ALIGNMENT

          Specialty Guideline Management coverage review will be
          bypassed for drug(s) being requested for a procedure that has
          been approved under a member’s medical benefit plan. Such
          members will be exempt from the requirements in Sections III.
          A medical authorization number and confirmation of the
          approved procedure(s) will be required.

          NOTE: Some plans may opt-out of medical benefit
          alignment. Members receiving coverage under such plans
          must meet the requirements in Sections III.


  III.  CRITERIA FOR INITIAL APPROVAL

          Follicle stimulation
          Authorization of 12 months may be granted for members
          undergoing ovulation induction or assisted reproductive
          technology (ART) who meet any of the following criteria:
          A.  Member has completed three or more previous cycles of
               clomiphene
          B.  Member has a risk factor for poor ovarian response to
               clomiphene
          C.  Member has a contraindication or exclusion to clomiphene
          D.  Member is 37 years of age or older


   IV.  CONTINUATION OF THERAPY

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

Place of Service:

Outpatient

The above policy is based on the following references:

1. Menopur [package insert]. Parsippany, NJ: Ferring Pharmaceuticals Inc.; May 2018.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

October 14, 2023