01Before billing the injectables Cetrotide (cetrorelix acetate), ganirelix acetate, Follistim AQ (follitropin beta), Gonal-F (follitropin alfa), Menopur (menotropins), Novarel and Pregnyl (chorionic gonadotropin), Ovidrel (choriogonadotropin alfa), and chorionic gonadotropin for applicable plan designs, obtain precertification from Aetna at (866) 782-2779 or by fax at (860) 754-2515, using the Statement of Medical Necessity forms under Specialty Pharmacy Precertification.
02For ART drugs used with an infertility procedure, the procedure must be approved under the member's medical benefit, and the precertification must include a medical authorization number and confirmation of that approval to bypass Specialty Pharmacy Guideline Management medical necessity review, unless the plan requires that review for all infertility drugs.
03Before billing ovulation induction or ART, confirm the trial of egg-sperm contact is documented in the medical record: for women under 35, 12 months of regular intravaginal inseminations or 4 cycles of timed intrauterine or intracervical inseminations, and for women 35 and older, 6 months of regular intravaginal inseminations or 3 cycles of timed intrauterine or intracervical insemination.
04For IVF, this trial requirement is waived when inseminations would not be expected to be effective and IVF is the only effective treatment.
05For ART using a woman's own eggs, confirm the unmedicated day 3 FSH is less than 19 mIU/mL in her most recent test if she is under 40, or in all prior unmedicated tests if she is 40 or older, and check benefit plan descriptions because some plans exclude this coverage.
06Serum FSH, not urinary FSH, is the standard of care, and urinary FSH testing is considered experimental, investigational, or unproven.
07Services the policy lists as experimental, investigational, or unproven are not covered, including PICSI, GIFT for male factor or unexplained infertility, and vaginal sildenafil.
08Most plans exclude infertility services after a sterilization procedure, including tubal sterilization and vasectomy, and after a hysterectomy, so check benefit plan descriptions before billing.
09Certain plans may not have this policy in effect until plan renewal, so check plan documents.