Subcutaneous Immune Globulin

Evicore covers subcutaneous immune globulins (Cutaquig, Cuvitru, Hizentra, HyQvia, Xembify) for FDA‑approved indications only — primary humoral immunodeficiencies (e.g., CVID, XLA, agammaglobulinemias, SCID, Wiskott‑Aldrich, Hyper‑IgM, DiGeorge, ataxia‑telangiectasia, IgG subclass deficiency, SAD, other genetic PIDs, and IgG <250 mg/dL) and CIDP maintenance in adults; non‑FDA uses are excluded. Coverage requires specialist prescribing/consultation (allergist/immunologist/ENT/pulmonologist/infectious disease for PID; neurologist for CIDP), appropriate diagnostic/laboratory confirmation (age‑adjusted low total IgG and/or impaired specific antibody responses plus recurrent infections as specified, electrodiagnostic confirmation for CIDP), adherence to initial and reauthorization criteria showing clinical benefit, HyQvia ramp‑up rules when applicable, and approval is granted for up to 12 months.

"Treatment of primary humoral immunodeficiency (FDA‑approved indication), including but not limited to: common variable immunodeficiency (CVID), x‑linked agammaglobulinemia, congenital agammaglobuli..."