Intravenous Immune Globulins (Alyglo, Asceniv, Bivigam, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen, Yimmugo)

Covers IVIG for a broad set of FDA‑approved and compendial off‑label indications (including primary and secondary humoral immunodeficiencies, ITP, CIDP, MMN, Kawasaki, GBS, autoimmune blistering diseases, transplant ABMR/desensitization, MOGAD/NMOSD, myasthenia gravis, dermatomyositis/polymyositis, CMV pneumonitis, parvovirus B19, etc.) and does not cover uses not listed. Key requirements include indication‑specific prior authorization with documented diagnostics and thresholds (e.g., age‑adjusted low total IgG or IgG <250–600 mg/dL as specified, positive disease‑specific antibodies like MOG‑IgG/AQP4‑IgG, electrodiagnostic/biopsy/MRI evidence for neuromuscular diseases), specialist prescriber/consultation, prior trials of steroids or other immunosuppressants unless contraindicated, timing/approval‑duration limits (e.g., GBS initiation window) and documented clinical benefit for reauthorization.

"Treatment or post-exposure prophylaxis for tetanus (when tetanus immune globulin is not available)"