Prior Authorization : Services Requiring Prior Authorization

Crinone

PA requests for Crinone may be approved for the treatment of secondary amenorrhea.

Although Crinone is also indicated for use in ART treatment, ForwardHealth does not cover infertility treatment, including ART.

PA requests for Crinone for the treatment of secondary amenorrhea must be submitted using Section VI (Clinical Information for Drugs with Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA and the PA/RF.

PA requests for Crinone for the treatment of secondary amenorrhea may be submitted on the ForwardHealth Portal, by fax, or by mail. PA requests for Crinone may not be submitted using the STAT-PA system.

Clinical Criteria for Crinone

Crinone may be used for the treatment of the following conditions:

• Secondary amenorrhea
• Prevention of preterm labor in women with a current singleton pregnancy and either short cervical length or a history of preterm labor

Although Crinone is also indicated for use in ART treatment, ForwardHealth does not cover infertility treatment, including ART.

For Members Who Have Secondary Amenorrhea

Secondary amenorrhea is the cessation of menses for six or more months in a woman who previously had normal menstrual cycles. Women who are pregnant, breastfeeding, or in menopause are not considered to have secondary amenorrhea.

Clinical criteria that must be documented for approval of a PA request for Crinone for members who have secondary amenorrhea are all of the following:

• The member has secondary amenorrhea.
• The member's last menstrual cycle occurred more than six months ago.
• The member is not being treated for infertility.
• The member is not pregnant or breastfeeding.
• The member is not in menopause.
• The member is currently receiving estrogen therapy.

Crinone 4% will only be approved for every-other-day dosing up to a total of six doses.

In women who fail to respond to a trial of Crinone 4%, Crinone 8% will only be approved for every-other-day dosing up to a total of six doses.

Crinone 8% for Women with a Current Singleton Pregnancy and Either Short Cervical Length or a History of Preterm Labor

ForwardHealth covers Crinone 8% for daily dosing through 36 weeks gestation in women with a current singleton pregnancy and either short cervical length or a history of preterm labor.

PA is not required for coverage of Crinone 8% in these situations; however, providers are required instead to follow the procedures for Diagnosis-Restricted Drugs.