Immunoglobulins

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
IMMUNE GLOBUL G/GLY/IGA AVG 46 GAMUNEX-C VIAL Y 10 gram/100 mL (10 %) Require PA  
IGG/HYALURONIDASE,RECOMBINANT HYQVIA VIAL N    
IMM GLOB G (IGG)/SORB/IGA 0-50 FLEBOGAMMA DIF VIAL N    
IMMUN GLOB G(IGG)/GLY/IGA OV50 GAMMAGARD LIQUID VIAL N    
IMMUN GLOB G(IGG)/GLY/IGA OV50 CUVITRU VIAL N    
IMMUN GLOB G(IGG)/GLY/IGA OV50 BIVIGAM VIAL N    
IMMUN GLOB G(IGG)/PRO/IGA 0-50 PRIVIGEN VIAL N    
IMMUN GLOB G(IGG)/PRO/IGA 0-50 HIZENTRA VIAL N    
IMMUN GLOBG(IGG)/MALT/IGA OV50 OCTAGAM VIAL N    
IMMUN GLOBG(IGG)/SUCR/IGA OV50 CARIMUNE NF NANOFILTERED VIAL N    
IMMUNE GLOBUL G/GLY/IGA AVG 46 GAMMAKED VIAL N    
IMMUN GLOB G/GLY/GLUC/IGA 0-50 GAMMAGARD S-D VIAL    
IMMUN GLOB G/SORB/GLY/IGA 0-50 GAMMAPLEX VIAL    
IMMUN GLOBG(IGG)/MALT/IGA OV50 OCTAGAM VIAL    
IMMUNE GLOBUL G (IGG)/GLYCINE GAMASTAN S-D VIAL