CommercialPrior AuthMedium impact
Follitropins and Menotropins (CPB 1082, reviewed 2026-10-09)
Aetna·OB-GYN, Endocrinology, Urology·Medical Policy
We identified it
Oct 10, 2026
Summary
Aetna's CPB 1082 policy on follitropins and menotropins was reviewed on 2026-10-09, establishing medical necessity criteria for injectable fertility medications in commercial plans. The policy requires precertification for Follistim AQ, Gonal-F, Gonal-F RFF, and Menopur, and outlines specific clinical criteria for coverage including prior treatment failures, age thresholds (37+), poor ovarian response risk factors, and contraindications to oral agents. Billing teams must verify precertification requirements and ensure claims align with documented clinical criteria.
Action Required
Billing team should implement the following ongoing procedures: (1) Require precertification for all Follistim AQ (follitropin beta), Gonal-F (follitropin alfa), Gonal-F RFF (follitropin alfa), and Menopur (menotropins) claims by contacting Aetna at (866) 782-2779 or faxing (860) 754-2515 before claim submission; (2) Verify that member claims meet at least one of the documented clinical criteria (prior clomiphene/letrozole cycles, poor ovarian response risk, contraindication to oral agents, or age 37+) before processing; (3) Confirm that infertility procedure authorization exists in the medical benefit when bypassing specialty pharmacy medical necessity review; (4) Use HCPCS codes S0122, S0126, S0128 only when precertification and clinical criteria are met; (5) Route all precertification requests through the Specialty Pharmacy Precertification process and retain medical authorization numbers for documentation; (6) Flag claims for codes 58974 and 89255 if billed solely for endometrium preparation for frozen embryo transfer, as these are not covered per policy. This policy applies to Aetna commercial plans only; confirm current plan applicability for each member before processing.