Immune Globulin Injection

This policy covers IVIG and SCIG for specified FDA‑approved and compendial off‑label indications (primary/secondary humoral immunodeficiencies; CIDP, GBS, multifocal motor neuropathy; refractory myasthenia gravis in defined roles; Kawasaki disease; ITP; transplant prophylaxis/treatment; certain infectious and autoimmune uses) and excludes requests for unlisted indications. Approvals are limited to 180 days and require documentation matching the covered indication (including prior therapy or refractory status where specified, IgG <400 mg/dL for HIV pediatric prophylaxis, transplant status, and product‑specific contraindication checks such as anti‑IgA antibodies, hereditary fructose intolerance/Gammaplex, hyperprolinemia/Hizentra/Privigen, hyaluronidase hypersensitivity/HyQvia), plus safety monitoring and rationale for product selection/infusion parameters (thrombosis and renal risk, avoid sucrose formulations in renal‑risk patients).

"Autoimmune diseases (approved off-label compendial uses)"