CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Coverage Criteria: Chorionic Gonadotropin (hCG) products (Novarel, Pregnyl, Ovidrel)

This policy governs coverage and prior authorization requirements for Novarel, Pregnyl, and Ovidrel (hCG products) when used for FDA‑approved and compendial reproductive and certain hypogonadal indications for members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChorionic Gonadotropin (hCG) products coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit pretreatment laboratory results including testosterone, FSH, and LH to initiate prior authorization for hypogonadotropic hypogonadism.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3FDA‑approved indication groups listed

12 moTypical auth length (ovulation induction/ART & hypogonadotropic hypogonadism)

6 moAuth length (prepubertal cryptorchidism)

3Brand products referenced

Coverage Criteria and Definitions

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Covered Indications and Required Supporting Information

Covered Indications and Required Supporting Information — Covered when ALL of the following are met for each indication group.

All FDA-approved and compendial indications as listed are considered medically necessary when documentation requirements are met.

All other indications are considered experimental/investigational and not medically necessary.

Use of hCG for indications other than the FDA‑approved or compendial infertility/luteal phase support indications is considered not medically necessary and is treated as experimental/investigational.

Denial Risk

Experimental/Investigational Denials

Requests for coverage for indications that are not listed as FDA‑approved or compendial will be denied as experimental/investigational and are not medically covered.

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior authorization required and time‑limits

Prior authorization is required for hCG products. Authorization durations: up to 12 months for ovulation induction/ART and for hypogonadotropic hypogonadism, and up to 6 months for prepubertal cryptorchidism.

Note

SGM bypass only for medically authorized procedures

Specialty Guideline Management (SGM) may be bypassed when the drug is requested for a procedure that has been approved under the member's medical benefit; otherwise follow SGM requirements.

Documentation Required

Provide medical authorization documentation to align with medical benefit

If the drug is being requested for a procedure already approved under the member's medical benefit plan, provide the medical authorization number and confirmation of the approved procedure(s) to bypass Specialty Guideline Management review.

Documentation Required

Submit pretreatment testosterone, FSH, and LH

For hypogonadotropic hypogonadism prior authorization, submit pretreatment laboratory results including testosterone, FSH, and LH levels.

Pretreatment testosterone level
Pretreatment follicle stimulating hormone (FSH) level
Pretreatment luteinizing hormone (LH) level

Clinical Background

Chorionic gonadotropin (hCG) products are used in reproductive medicine for roles such as induction of ovulation, final follicular maturation, and luteal support in assisted reproductive technologies, and for certain pediatric or hypogonadal conditions. Uses recognized in compendia (for example, infertility and luteal phase support) are considered covered when policy criteria are met; all other uses are considered experimental/investigational and not medically necessary.