Chorionic gonadotropin injection 10,000 unit vials — Cigna
prepubertal cryptorchidism not due to an anatomical obstruction
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