Intravenous Immune Globulin
EVICORE-MEDICAL_DRUG-0C7B0409
Covers IVIG for listed FDA‑approved indications (e.g., primary humoral immunodeficiencies, ITP, CIDP, MMN, Kawasaki, etc.) and specified compendial off‑label uses; non‑compendial/unlisted off‑label uses are not covered. Key requirements include documented diagnosis with indication‑specific criteria (e.g., pretreatment low IgG or impaired antibody response and/or recurrent infections; specific thresholds such as IgG <600 mg/dL for CLL/hematologic indications and <400 mg/dL for pediatric HIV), prescription/consultation by an appropriate specialist, required prior therapy trials where noted, adherence to dosing/timing/approval‑duration limits, and demonstration of clinical benefit for reauthorization.
"Immunotherapy-related toxicities associated with checkpoint inhibitor therapy"
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