Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

A.P.L. Chorionic Gonadotropin   Not Applicable Bravelle urofollitropin (FSH) 75 unit Recon Soln   Not Applicable Chorex-10 chorionic gonadotropin, human 10,000 unit Recon Soln   Not Applicable Clomid clomiphene citrate 50 mg tablet   Not Applicable Follistim AQ follitropin beta 300 unit/0.36 mL Cartridge; 600 unit/0.72 mL Cartridge; 900 unit/1.08 mL Cartridge   Not Applicable Follistim AQ follitropin beta 75 unit/0.5 mL Solution; 150 unit/0.5 mL Solution   Not Applicable Gonal-F follitropin alfa 1,050 unit Recon Soln; 450 unit Recon Soln; 37.5 unit Recon Soln; 150 unit Recon Soln   Not Applicable Gonal-f RFF follitropin alfa 75 unit Recon Soln   Not Applicable Menopur menotropins 75 unit Recon Soln   Not Applicable Novarel chorionic gonadotropin, human 10,000 unit Recon Soln   Not Applicable Ovidrel choriogonadotropin alfa,humrec 250 mcg/0.5 mL Syringe   Not Applicable Pregnyl chorionic gonadotropin, human 10,000 unit Recon Soln   Not Applicable Profasi HP chorionic gonadotropin, human 10,000 unit Recon Soln   Not Applicable Repronex menotropins 75 unit Recon Soln   Not Applicable Serophene clomiphene citrate 50 mg tablet   Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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