Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and Subcutaneous Ig [SCIG])

This policy covers immunoglobulin therapy (intravenous IVIG and subcutaneous SCIG) for medically indicated immune and hematologic conditions — including primary humoral immunodeficiencies, selective IgG subclass deficiency, specific antibody deficiency, acute immune thrombocytopenia with severe thrombocytopenia, acquired factor VIII inhibitors/then von Willebrand disorder, acute disseminated encephalitis, and other listed immune‑mediated disorders. Coverage requires evidence of effectiveness in peer‑reviewed literature or authoritative sources with dosing/frequency/duration consistent with FDA labeling/compendia/guidelines; non‑preferred agents generally require prior trial/failure or documented benefit for continuation, certain immunodeficiency evaluations require pre/post pneumococcal antibody testing, and benefits are subject to member plan and state‑specific limitations while experimental/unsupported uses are excluded.

"Requested drug therapy is covered when it is proven effective for the relevant diagnosis or procedure based on current peer‑reviewed scientific literature."