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Chorionic gonadotropin injection 10,000 unit vials — Cigna

hypogonadotropic hypogonadism (hypogonadism secondary to pituitary deficiency)

Initial criteria

  • If the patient has prepubertal cryptorchidism not due to an anatomical obstruction, approve the requested quantity, not to exceed a total of 4 vials per dispensing at retail and 12 vials per dispensing at home delivery.
  • If the patient has hypogonadotropic hypogonadism (hypogonadism secondary to pituitary deficiency), approve the requested quantity, not to exceed a total of 6 vials per dispensing at retail and 18 vials per dispensing at home delivery.

Approval duration

1 year