Skip to content
The Policy VaultThe Policy Vault

Chorionic Gonadotropin for injection — Cigna

cryptorchidism

Preferred products

  • Ovidrel
  • Pregnyl
  • Novarel

Initial criteria

  • National Preferred, High Performance Formulary: Approve for 1 year if the patient has cryptorchidism or hypogonadism AND has tried Pregnyl.
  • National Preferred, High Performance Formulary: Approve for 1 year if the patient has infertility or induction of ovulation AND the patient’s benefit includes infertility coverage AND has tried ONE of the following: Pregnyl or Ovidrel.
  • National Preferred, High Performance Formulary: Approve for 1 year if the patient’s benefit does NOT include infertility coverage AND benefit exclusion overrides are utilized AND patient meets BOTH of the following (A and B): A) Patient meets the standard Chorionic Gonadotropins Benefit Exclusion Overrides Policy criteria; AND B) Patient has tried Pregnyl.
  • Basic Formulary: Approve for 1 year if the patient has cryptorchidism or hypogonadism AND has tried Novarel.
  • Basic Formulary: Approve for 1 year if the patient has infertility or induction of ovulation AND the patient’s benefit includes infertility coverage AND has tried ONE of the following: Novarel or Ovidrel.
  • Basic Formulary: Approve for 1 year if the patient’s benefit does NOT include infertility coverage AND benefit exclusion overrides are utilized AND patient meets BOTH of the following (A and B): A) Patient meets the standard Chorionic Gonadotropins Benefit Exclusion Overrides Policy criteria; AND B) Patient has tried Novarel.

Approval duration

1 year