Medicare AdvantagePrior AuthMedium impact
Novarel®, Pregnyl® (human chorionic gonadotropin) (Revised)
Humana·Urology, Endocrinology, Pediatrics +1 more·Medicare Advantage
Effective date
May 27, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its prior authorization policy for Novarel and Pregnyl (human chorionic gonadotropin) effective May 27, 2026. The policy maintains prior authorization requirements for four approvable indications (hypogonadotropic hypogonadism in males, prepubertal cryptorchidism, AIDS-related Kaposi's sarcoma, and hypospadias) while explicitly excluding coverage for infertility, obesity, erectile dysfunction, precocious puberty, and androgen-dependent neoplasms without additional clinical justification. Billing teams must ensure claims are submitted only for the four covered indications and implement prior authorization processes before the effective date.
Action Required
Before May 27, 2026: Billing team must update prior authorization workflows to require pre-approval for all Novarel and Pregnyl (hCG) prescriptions. Implement claim screening logic to deny or hold claims for the following diagnoses without approvable clinical documentation: female/male infertility, obesity, erectile dysfunction, precocious puberty, and prostatic/androgen-dependent carcinomas. Educate providers on the four approvable indications only: hypogonadotropic hypogonadism secondary to pituitary deficiency in males, prepubertal cryptorchidism (non-anatomical), AIDS-related Kaposi's sarcoma, and hypospadias. Update encounter forms and billing templates to flag hCG requests for prior authorization. Failure to obtain prior authorization or billing for excluded diagnoses will result in claim denials for Medicare Advantage members.