Intravenous Immune Globulin Injection

IVIG is covered for FDA‑approved indications and specified compendial off‑label uses (e.g., primary/secondary humoral immunodeficiencies, CIDP/MMN/GBS/ITP/transplant desensitization/ABMR, select autoimmune and infection‑related indications) and is not covered for indications not on the policy list. Coverage requires indication‑specific documentation including specialist prescription/consultation, required laboratory criteria (e.g., age‑adjusted low IgG on ≥2 occasions >3 weeks apart or IgG <500 mg/dL for many secondary immunodeficiencies), evidence of impaired antibody response or required prior therapy trials (e.g., steroids for ITP), adherence to timing/age limits, and objective clinical response or target IgG troughs for reauthorization.

"PID — CVID/unspecified hypogammaglobulinemia: patient must be ≥ 2 years of age."

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