Immunoglobulins

← Back to Class List

PDL Reference Documents

Drug Use Review Documents

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.
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.

< Return to summary view

NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
00944251202 HYQVIA IgG/hyaluronidase,recombinant VIAL 10 gram/100 mL (10 %)-800 unit/5 mL N Y PA Document
00944251002 HYQVIA IgG/hyaluronidase,recombinant VIAL 2.5 gram/25 mL (10 %)-200 unit/1.25 mL N Y PA Document
00944251302 HYQVIA IgG/hyaluronidase,recombinant VIAL 20 gram/200 mL (10 %)-1,600 unit/10 mL N Y PA Document
00944251402 HYQVIA IgG/hyaluronidase,recombinant VIAL 30 gram/300 mL (10 %)-2,400 unit/15 mL N Y PA Document
00944251102 HYQVIA IgG/hyaluronidase,recombinant VIAL 5 gram/50 mL (10 %)-400 unit/2.5 mL N Y PA Document
00069106101 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
00069106102 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
00069147601 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
00069147602 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
00069150901 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
00069150902 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
00069196501 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
00069196502 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081001 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081002 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081003 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081004 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081005 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081006 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081081 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081082 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081083 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081084 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081085 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
68982081086 CUTAQUIG immun glob G(IgG)-hipp/maltose VIAL 16.5 % N Y PA Document
00069101101 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
00069101102 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
00069110901 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
00069110902 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
00069122401 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
00069122402 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
00069131201 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
00069131202 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
00069141501 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
00069141502 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
00069155801 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
00069155802 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082201 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082202 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082203 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082204 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082205 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082206 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082281 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082282 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082283 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082284 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082285 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
68982082286 PANZYGA immun glob G(IgG)-ifas/glycine VIAL 10 % N Y PA Document
64208823501 GAMMAPLEX immun glob G(IgG)/gly/IgA 0-50 VIAL 10 % N Y PA Document
64208823502 GAMMAPLEX immun glob G(IgG)/gly/IgA 0-50 VIAL 10 % N Y PA Document
64208823503 GAMMAPLEX immun glob G(IgG)/gly/IgA 0-50 VIAL 10 % N Y PA Document
64208823505 GAMMAPLEX immun glob G(IgG)/gly/IgA 0-50 VIAL 10 % N Y PA Document
64208823506 GAMMAPLEX immun glob G(IgG)/gly/IgA 0-50 VIAL 10 % N Y PA Document
64208823507 GAMMAPLEX immun glob G(IgG)/gly/IgA 0-50 VIAL 10 % N Y PA Document
00944285001 CUVITRU immun glob G(IgG)/gly/IgA ov50 VIAL 1 gram/5 mL (20 %) N Y PA Document
00944285002 CUVITRU immun glob G(IgG)/gly/IgA ov50 VIAL 1 gram/5 mL (20 %) N Y PA Document
69800650201 BIVIGAM immun glob G(IgG)/gly/IgA ov50 VIAL 10 % N Y PA Document
69800650202 BIVIGAM immun glob G(IgG)/gly/IgA ov50 VIAL 10 % N Y PA Document
69800650301 BIVIGAM immun glob G(IgG)/gly/IgA ov50 VIAL 10 % N Y PA Document
69800650302 BIVIGAM immun glob G(IgG)/gly/IgA ov50 VIAL 10 % N Y PA Document
00944270002 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944270003 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944270004 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944270005 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944270006 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944270007 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944270008 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944270009 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944270010 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944270011 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944270012 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944270013 GAMMAGARD LIQUID immun glob G(IgG)/gly/IgA ov50 VIAL 10 % Y Y  
00944271710 HYQVIA IG COMPONENT immun glob G(IgG)/gly/IgA ov50 VIAL 10 gram/100 mL (10 %) N Y PA Document
00944285009 CUVITRU immun glob G(IgG)/gly/IgA ov50 VIAL 10 gram/50 mL (20 %) N Y PA Document
00944285003 CUVITRU immun glob G(IgG)/gly/IgA ov50 VIAL 2 gram/10 mL (20 %) N Y PA Document
00944285004 CUVITRU immun glob G(IgG)/gly/IgA ov50 VIAL 2 gram/10 mL (20 %) N Y PA Document
00944271525 HYQVIA IG COMPONENT immun glob G(IgG)/gly/IgA ov50 VIAL 2.5 gram/25 mL (10 %) N Y PA Document
00944271820 HYQVIA IG COMPONENT immun glob G(IgG)/gly/IgA ov50 VIAL 20 gram/200 mL (10 %) N Y PA Document
00944271930 HYQVIA IG COMPONENT immun glob G(IgG)/gly/IgA ov50 VIAL 30 gram/300 mL (10 %) N Y PA Document
00944285005 CUVITRU immun glob G(IgG)/gly/IgA ov50 VIAL 4 gram/20 mL (20 %) N Y PA Document
00944285006 CUVITRU immun glob G(IgG)/gly/IgA ov50 VIAL 4 gram/20 mL (20 %) N Y PA Document
00944271605 HYQVIA IG COMPONENT immun glob G(IgG)/gly/IgA ov50 VIAL 5 gram/50 mL (10 %) N Y PA Document
00944285007 CUVITRU immun glob G(IgG)/gly/IgA ov50 VIAL 8 gram/40 mL (20 %) N Y PA Document
00944285008 CUVITRU immun glob G(IgG)/gly/IgA ov50 VIAL 8 gram/40 mL (20 %) N Y PA Document
44206045621 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 SYRINGE 1 gram/5 mL (20 %) Y Y  
44206045694 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 SYRINGE 1 gram/5 mL (20 %) Y Y  
44206045525 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 SYRINGE 10 gram/50 mL (20 %) Y Y  
44206045597 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 SYRINGE 10 gram/50 mL (20 %) Y Y  
44206045722 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 SYRINGE 2 gram/10 mL (20 %) Y Y  
44206045795 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 SYRINGE 2 gram/10 mL (20 %) Y Y  
44206045824 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 SYRINGE 4 gram/20 mL (20 %) Y Y  
44206045896 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 SYRINGE 4 gram/20 mL (20 %) Y Y  
44206045101 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 VIAL 1 gram/5 mL (20 %) Y Y  
44206045190 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 VIAL 1 gram/5 mL (20 %) Y Y  
44206043605 PRIVIGEN immun glob G(IgG)/pro/IgA 0-50 VIAL 10 % Y Y  
44206043690 PRIVIGEN immun glob G(IgG)/pro/IgA 0-50 VIAL 10 % Y Y  
44206043710 PRIVIGEN immun glob G(IgG)/pro/IgA 0-50 VIAL 10 % Y Y  
44206043791 PRIVIGEN immun glob G(IgG)/pro/IgA 0-50 VIAL 10 % Y Y  
44206043820 PRIVIGEN immun glob G(IgG)/pro/IgA 0-50 VIAL 10 % Y Y  
44206043892 PRIVIGEN immun glob G(IgG)/pro/IgA 0-50 VIAL 10 % Y Y  
44206043940 PRIVIGEN immun glob G(IgG)/pro/IgA 0-50 VIAL 10 % Y Y  
44206043993 PRIVIGEN immun glob G(IgG)/pro/IgA 0-50 VIAL 10 % Y Y  
44206045510 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 VIAL 10 gram/50 mL (20 %) Y Y  
44206045593 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 VIAL 10 gram/50 mL (20 %) Y Y  
44206045202 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 VIAL 2 gram/10 mL (20 %) Y Y  
44206045291 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 VIAL 2 gram/10 mL (20 %) Y Y  
44206045404 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 VIAL 4 gram/20 mL (20 %) Y Y  
44206045492 HIZENTRA immun glob G(IgG)/pro/IgA 0-50 VIAL 4 gram/20 mL (20 %) Y Y  
00944265804 GAMMAGARD S-D immun glob G/gly/gluc/IgA 0-50 VIAL 10 gram N Y PA Document
00944265908 GAMMAGARD S-D immun glob G/gly/gluc/IgA 0-50 VIAL 10 gram N Y PA Document
00944265603 GAMMAGARD S-D immun glob G/gly/gluc/IgA 0-50 VIAL 5 gram N Y PA Document
00944265707 GAMMAGARD S-D immun glob G/gly/gluc/IgA 0-50 VIAL 5 gram N Y PA Document
64208823402 GAMMAPLEX immun glob G/sorb/gly/IgA 0-50 VIAL 5 % N Y PA Document
64208823403 GAMMAPLEX immun glob G/sorb/gly/IgA 0-50 VIAL 5 % N Y PA Document
64208823404 GAMMAPLEX immun glob G/sorb/gly/IgA 0-50 VIAL 5 % N Y PA Document
64208823406 GAMMAPLEX immun glob G/sorb/gly/IgA 0-50 VIAL 5 % N Y PA Document
64208823407 GAMMAPLEX immun glob G/sorb/gly/IgA 0-50 VIAL 5 % N Y PA Document
64208823408 GAMMAPLEX immun glob G/sorb/gly/IgA 0-50 VIAL 5 % N Y PA Document
00069600201 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
00069600202 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
00069611101 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
00069611102 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
00069623701 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
00069623702 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
00069633901 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
00069633902 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
00069655001 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
00069655002 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
68982085001 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
68982085002 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
68982085003 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
68982085004 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
68982085005 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 10 % N Y PA Document
00069840001 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
00069840002 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
00069842501 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
00069842502 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
00069845101 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
00069845102 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
00069847601 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
00069847602 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
68982084001 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
68982084002 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
68982084003 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
68982084004 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
68982084005 OCTAGAM immun globG(IgG)/malt/IgA ov50 VIAL 5 % N Y PA Document
13533033504 GAMASTAN immune globul G (IgG)/glycine VIAL 15 %-18 % range N Y PA Document
13533033512 GAMASTAN immune globul G (IgG)/glycine VIAL 15 %-18 % range N Y PA Document
13533033513 GAMASTAN immune globul G (IgG)/glycine VIAL 15 %-18 % range N Y PA Document
13533033540 GAMASTAN immune globul G (IgG)/glycine VIAL 15 %-18 % range N Y PA Document
76125090001 GAMMAKED immune globul G/gly/IgA avg 46 VIAL 1 gram/10 mL (10 %) N Y PA Document
76125090002 GAMMAKED immune globul G/gly/IgA avg 46 VIAL 1 gram/10 mL (10 %) N Y PA Document
13533080012 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 1 gram/10 mL (10 %) N Y PA Document
13533080013 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 1 gram/10 mL (10 %) N Y PA Document
76125090010 GAMMAKED immune globul G/gly/IgA avg 46 VIAL 10 gram/100 mL (10 %) N Y PA Document
76125090011 GAMMAKED immune globul G/gly/IgA avg 46 VIAL 10 gram/100 mL (10 %) N Y PA Document
13533080071 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 10 gram/100 mL (10 %) N Y PA Document
13533080072 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 10 gram/100 mL (10 %) N Y PA Document
13533080015 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 2.5 gram/25 mL (10 %) N Y PA Document
13533080016 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 2.5 gram/25 mL (10 %) N Y PA Document
76125090020 GAMMAKED immune globul G/gly/IgA avg 46 VIAL 20 gram/200 mL (10 %) N Y PA Document
76125090021 GAMMAKED immune globul G/gly/IgA avg 46 VIAL 20 gram/200 mL (10 %) N Y PA Document
13533080024 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 20 gram/200 mL (10 %) N Y PA Document
13533080025 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 20 gram/200 mL (10 %) N Y PA Document
13533080040 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 40 gram/400 mL (10 %) N Y PA Document
13533080041 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 40 gram/400 mL (10 %) N Y PA Document
76125090050 GAMMAKED immune globul G/gly/IgA avg 46 VIAL 5 gram/50 mL (10 %) N Y PA Document
76125090051 GAMMAKED immune globul G/gly/IgA avg 46 VIAL 5 gram/50 mL (10 %) N Y PA Document
13533080020 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 5 gram/50 mL (10 %) N Y PA Document
13533080021 GAMUNEX-C immune globul G/gly/IgA avg 46 VIAL 5 gram/50 mL (10 %) N Y PA Document
00053748601 GAMMAR-P I.V. immune globulin,gamma(IgG) VIAL 1 gram N Y PA Document
00078012094 SANDOGLOBULIN immune globulin,gamma(IgG) VIAL 1 gram N Y PA Document
44206050653 IMMUNE GLOBULIN immune globulin,gamma(IgG) VIAL 3 gram N Y PA Document
00053748606 GAMMAR-P I.V. immune globulin,gamma(IgG) VIAL 5 gram N Y PA Document
44206050756 CARIMUNE immune globulin,gamma(IgG) VIAL 6 gram N Y PA Document
13533081005 XEMBIFY immune globulin,gamma(IgG)klhw VIAL 1 gram/5 mL (20 %) N Y PA Document
13533081006 XEMBIFY immune globulin,gamma(IgG)klhw VIAL 1 gram/5 mL (20 %) N Y PA Document
13533081050 XEMBIFY immune globulin,gamma(IgG)klhw VIAL 10 gram/50 mL (20 %) N Y PA Document
13533081051 XEMBIFY immune globulin,gamma(IgG)klhw VIAL 10 gram/50 mL (20 %) N Y PA Document
13533081010 XEMBIFY immune globulin,gamma(IgG)klhw VIAL 2 gram/10 mL (20 %) N Y PA Document
13533081011 XEMBIFY immune globulin,gamma(IgG)klhw VIAL 2 gram/10 mL (20 %) N Y PA Document
13533081020 XEMBIFY immune globulin,gamma(IgG)klhw VIAL 4 gram/20 mL (20 %) N Y PA Document
13533081021 XEMBIFY immune globulin,gamma(IgG)klhw VIAL 4 gram/20 mL (20 %) N Y PA Document
69800025001 ASCENIV immune globulin,gamma(IgG)slra VIAL 10 % N Y PA Document
69800025002 ASCENIV immune globulin,gamma(IgG)slra VIAL 10 % N Y PA Document
Back to Top ↑