Skip to content
The Policy VaultThe Policy Vault

Novarel 5,000 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 8 vials per dispensing at retail and 24 vials per dispensing at home delivery.
  • If the patient has hypogonadotropic hypogonadism (hypogonadism secondary to pituitary deficiency), approve the requested quantity, not to exceed 12 vials per dispensing at retail and 36 vials per dispensing at home delivery.

Approval duration

1 year