Subcutaneous Immune Globulins (Cutaquig, Cuvitru, Gammagard Liquid, Gammaked, Gamunex-C, Hizentra, HyQvia, Xembify)
EVICORE-MEDICAL_DRUG-EE7DDCFE
Covers FDA‑approved subcutaneous immune globulin products for primary humoral immunodeficiencies (e.g., CVID, X‑linked/congenital agammaglobulinemia, SCID, Wiskott‑Aldrich, IgG subclass deficiency, SAD, etc.) and CIDP maintenance, and excludes non‑FDA indications. Key requirements: meet diagnosis‑specific criteria (age‑adjusted low IgG where required, impaired antibody response and/or recurrent infections — both required for IgG subclass deficiency/SAD), prescribed by or in consultation with an appropriate specialist (allergist/immunologist/ENT/pulmonologist/infectious disease for immunodeficiency; neurologist for CIDP) with electrodiagnostic confirmation for CIDP, documentation of benefit for reauthorization, and approvals limited to 12 months.
"Subcutaneous immune globulin (SCIG) injection is indicated for the treatment of: - Primary humoral immunodeficiency including but not limited to, congenital agammaglobulinemia, common variable immu..."