Immunoglobulins

← Back to Class List

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 CUVITRU VIAL N    
immun glob G(IgG)/gly/IgA ov50 GAMMAGARD LIQUID VIAL N    
immun glob G(IgG)/gly/IgA ov50 BIVIGAM VIAL N    
immun glob G(IgG)/pro/IgA 0-50 HIZENTRA VIAL N    
immun glob G(IgG)/pro/IgA 0-50 PRIVIGEN 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