Effective July 5, 2016

UNIVERSITY OF MICHIGAN – – INFERTILITY: OVIDREL (Choriogonadotropin Alfa [hCG Alpha],

Recombinant)

Some of the information needed to make a determination for coverage is not specifically requested on

the Michigan Prior Authorization Request Form for Prescription Drugs. To avoid delays in reviewing your

request, please make sure to include all of the following information.

You must answer ALL questions related to your patient's condition 1. Is the patient female? Y N

2. Is the patient pregnant? Y N

3. Does the patient have the diagnosis of infertility? Y N

4. Does the patient have a diagnosis of primary ovarian failure? Y N

5. Is the patient undergoing:

induction of final follicular maturation and early luteinization, undergone pituitary desensitization and been appropriately pretreated with follicle-stimulating hormones (FSH) as part of an Assisted Reproductive Technology (ART) program, or

induction of ovulation and pregnancy?

Y N

6. Has the patient’s partner been evaluated for fertility potential AND been found to be fertile? NA Y N

N/A=not applicable