Follitropins and Menotropins (CPB 1082, reviewed 2026-04-10)

Immediately effective as of April 10, 2026: (1) Billing team must update system to REQUIRE precertification for all claims using HCPCS codes S0122 (menotropins 75 IU), S0126 (follitropin alfa 75 IU), and S0128 (follitropin beta 75 IU) on Aetna commercial plans. (2) Route all precertification requests to Aetna Specialty Pharmacy via phone (866) 782-2779 or fax (860) 754-2515. (3) Update encounter templates and prior authorization forms to capture: member's age, previous clomiphene/letrozole cycle count (if applicable), documented risk factors for poor ovarian response, contraindications to oral agents, hypogonadism labs (testosterone, FSH/LH levels), and whether the drug is for use with an approved infertility procedure. (4) For approved infertility procedures, obtain medical authorization number during precertification to potentially bypass Specialty Pharmacy medical necessity review (confirm plan type as some plans require review regardless). (5) Flag claims for CPT 58974 and 89255 if used solely for endometrium preparation for frozen embryo transfer—these are NOT covered. (6) Providers and billing staff should verify plan documents as some plans exclude infertility injectable medications entirely or limit menotropin cycles to a maximum number per lifetime. Failure to obtain required precertification will result in claim denials.