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

IVIG (listed products) is covered for the policy’s array of FDA‑approved and compendial off‑label indications (e.g., primary/secondary humoral immunodeficiency, ITP, CIDP, MMN, Kawasaki, dermatomyositis, GBS, myasthenia gravis, transplant antibody‑mediated rejection, post‑HCT hypogammaglobulinemia, measles/varicella/tetanus prophylaxis, etc.) and is not covered if the specific clinical criteria are not met. Coverage requires indication‑specific documentation and prescriber specialty/consultation, lab thresholds (e.g., low/age‑adjusted IgG, often <600 mg/dL or <400 mg/dL for pediatric HIV), diagnostic confirmation (impaired antibody response, electrodiagnostics, etc.), prior therapy trials when required, evidence of benefit for reauthorization, and adherence to specified approval durations.

"Human immunodeficiency virus (HIV) associated thrombocytopenia"

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