Immunoglobulins

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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    
immun glob G(IgG)-ifas/glycine PANZYGA 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)/gly/IgA ov50 HYQVIA IG COMPONENT VIAL N    
immun glob G(IgG)/gly/IgA ov50 GAMMAGARD LIQUID VIAL N    
immun glob G(IgG)/pro/IgA 0-50 HIZENTRA SYRINGE N    
immun glob G(IgG)/pro/IgA 0-50 HIZENTRA VIAL N    
immun glob G(IgG)/pro/IgA 0-50 PRIVIGEN 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) GAMMAR-P I.V. VIAL    
immune globulin,gamma(IgG) IMMUNE GLOBULIN VIAL    
immune globulin,gamma(IgG) SANDOGLOBULIN VIAL