Immunoglobulins
PDL Reference Documents
Drug Use Review Documents
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
|---|---|---|---|---|---|
| immune globul G/gly/IgA avg 46 | GAMUNEX-C | VIAL | Y | ||
| IgG/hyaluronidase,recombinant | HYQVIA | VIAL | N | ||
| imm glob G (IgG)/sorb/IgA 0-50 | FLEBOGAMMA DIF | VIAL | N | ||
| immun glob G(IgG)-ifas/glycine | PANZYGA | VIAL | N | ||
| immun glob G(IgG)/gly/IgA ov50 | HYQVIA IG COMPONENT | VIAL | N | ||
| immun glob G(IgG)/gly/IgA ov50 | GAMMAGARD LIQUID | VIAL | N | ||
| immun glob G(IgG)/gly/IgA ov50 | CUVITRU | VIAL | N | ||
| immun glob G(IgG)/gly/IgA ov50 | BIVIGAM | VIAL | N | ||
| immun glob G(IgG)/pro/IgA 0-50 | HIZENTRA | SYRINGE | N | ||
| immun glob G(IgG)/pro/IgA 0-50 | PRIVIGEN | VIAL | N | ||
| immun glob G(IgG)/pro/IgA 0-50 | HIZENTRA | VIAL | N | ||
| immun globG(IgG)/malt/IgA ov50 | OCTAGAM | VIAL | N | ||
| immune globul G/gly/IgA avg 46 | GAMMAKED | VIAL | N | ||
| immune globulin,gamma(IgG) | CARIMUNE | VIAL | N | ||
| immune globulin,gamma(IgG)klhw | XEMBIFY | VIAL | N | ||
| immune globulin,gamma(IgG)slra | ASCENIV | VIAL | N | ||
| immun glob G(IgG)-hipp/maltose | CUTAQUIG | VIAL | |||
| immun glob G(IgG)/gly/IgA 0-50 | GAMMAPLEX | VIAL | |||
| immun glob G/gly/gluc/IgA 0-50 | GAMMAGARD S-D | VIAL | |||
| immun glob G/sorb/gly/IgA 0-50 | GAMMAPLEX | VIAL | |||
| immun globG(IgG)/malt/IgA ov50 | OCTAGAM | VIAL | |||
| immune globul G (IgG)/glycine | GAMASTAN | VIAL | |||
| immune globulin,gamma(IgG) | IMMUNE GLOBULIN | VIAL | |||
| immune globulin,gamma(IgG) | SANDOGLOBULIN | VIAL | |||
| immune globulin,gamma(IgG) | GAMMAR-P I.V. | VIAL |