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Novarel — Cigna

hypogonadism

Preferred products

  • Ovidrel
  • Pregnyl

Initial criteria

  • Cryptorchidism or hypogonadism: Approve for 1 year if the patient has tried Pregnyl.
  • Infertility or induction of ovulation AND the patient’s benefit includes infertility coverage: Approve for 1 year if the patient has tried one of the following: Pregnyl or Ovidrel.
  • Patient’s benefit does NOT include infertility coverage AND benefit exclusion overrides are utilized: Approve for 1 year if BOTH of the following (A and B) are met: A) Patient meets the standard Chorionic Gonadotropins Benefit Exclusion Overrides Policy criteria; AND B) Patient has tried Pregnyl.

Approval duration

1 year