CurrentAvMedPolicy N/A

Pharmacy prior authorization/step-edit request for chorionic gonadotropin products

Form and policy governing prior authorization requests for chorionic gonadotropin drugs (e.g., Novarel, Ovidrel, Pregnyl) for AvMed members; specifies required provider signatures, member/prescriber/data elements, and clinical criteria for approval.

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization/step-edit request for chorionic gonadotropin products

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescribing physician must sign and fax the prior authorization form with required documentation to complete the request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4listed drug options on form

2 monthsapproval duration

1prescriber signature required

Specialtydispensing channel

Coverage Criteria for Chorionic Gonadotropin Products

Initial approval for prepubertal cryptorchidism

Covered when ALL of the following are met

Prepubertal cryptorchidism approval

Age requirement: Patient is between 4-9 years of age4-9 years
Diagnosis requirement: Patient has a diagnosis of prepubertal cryptorchidism NOT due to anatomical obstruction

Administrative and documentation requirements: All supporting documentation (lab results, diagnostics, and chart notes) must be provided for each checked clinical criterion; incomplete or illegible submissions may delay or cause denial

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization/step-edit request for chorionic gonadotropin products

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescribing physician must sign and fax the prior authorization form with required documentation to complete the request.

SourceLink

On This Page

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Use of drug samples to initiate therapy does not satisfy step-edit/PA requirements; previous therapies will be verified via pharmacy paid claims or chart notes

Exclusion: Cryptorchidism due to anatomical obstruction is not eligible under the approval criteria for chorionic gonadotropin therapy and is explicitly excluded from coverage under the listed approval conditions.

Step-edit / PA requirement: Use of drug samples to initiate therapy does not meet step edit/preauthorization criteria and therefore does not satisfy prior authorization requirements. Previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Diagnosis and Coding

Diagnosis Codes (to be supplied)ICD-10

ICD code

ICD Code, if applicable (to be filled by prescriber)

Age range for cryptorchidism approval

Age rangePatient is between 4-9 years of age

Approval duration2 months when criteria met

ApplicabilityApplies to prepubertal cryptorchidism treatment requests on the AvMed PA form

Provider Requirements and Submission Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required. The prescribing physician must sign and clearly print their name on the prior authorization form (preprinted signature stamps are not valid). Fax the completed form to 1-305-671-0200. Ensure the request is complete, correct, and legible — incomplete, incorrect, or illegible submissions may delay processing or result in denial.

Prescriber signature and printed name required (no preprinted stamps).
Fax number for submission: 1-305-671-0200.
Incomplete/illegible submissions may delay or cause denial.

Documentation Required

Provide Supporting Clinical Documentation

All documentation supporting each checked clinical criterion must be supplied with the request. This includes relevant laboratory results, diagnostics, and chart notes. Failure to provide supporting documentation for each checked criterion may result in denial of the authorization.

Provide lab results, imaging or other diagnostics, and contemporaneous chart notes that substantiate each checked clinical criterion.
All supporting documentation must specifically correspond to the clinical criteria selected on the form.

Note

Member and Prescriber Information Required

Provide complete member and prescriber information on the form. Authorization may be delayed if any required fields are incomplete.

Member name
Member AvMed #
Date of birth
Prescriber name
Prescriber signature and date
Office contact name, phone number, and fax number
Prescriber DEA or NPI number

Note

Provide Drug Details

Complete drug-specific details on the form. Authorization may be delayed if drug information is incomplete.

Drug form and strength
Dosing schedule
Length of therapy
Diagnosis and ICD code (if applicable)
Patient weight and date

Step Therapy

Step-Edit / Prior Therapy Verification

Step-edit and prior therapy verification rules apply. Use of samples to initiate therapy does not satisfy step-edit or prior authorization criteria. Previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Samples cannot be used to meet prior therapy or step-edit requirements.
Prior therapies may be confirmed via pharmacy claims history or chart note documentation.

Background

Chorionic gonadotropin products are indicated on the PA form for short-term treatment of prepubertal cryptorchidism when specific clinical criteria are met, including the patient being between 4-9 years of age and having cryptorchidism not due to anatomical obstruction. When these criteria are satisfied the form documents consideration for a 2-month approval; medication dispensing is noted to occur via Specialty Pharmacy (PropriumRx).

Definitions

prepubertal cryptorchidism NOT due to anatomical obstruction

DefinitionPrepubertal cryptorchidism NOT due to anatomical obstruction

Exclusion noteCryptorchidism due to anatomical obstruction is excluded from the listed approval criteria

Documentation requirementDocumentation must be provided for each checked clinical criterion; use of samples does not meet step-edit/PA criteria

Initial Therapy Criteria

Initial therapy for cryptorchidism

Initial approval criteria for listed chorionic gonadotropin products

Initial therapy criteria: Patient age between 4-9 years AND diagnosis of prepubertal cryptorchidism not due to anatomical obstruction; documentation must be provided2 months

Medication will be provided by Specialty Pharmacy (PropriumRx); samples do not meet step-edit/PA requirements

Step Therapy and Prior Treatment Verification

Requirement	Verification / Notes
Previous therapies must be verified through pharmacy paid claims or submitted chart notes.
Use of drug samples to initiate therapy does not meet step edit / preauthorization criteria and does not satisfy step requirements.

Dispensing and Site-of-Care

Note

Specialty pharmacy dispensing must be noted

Indicate on the form if the medication will be dispensed via Specialty Pharmacy (PropriumRx).