Immune Globulins Intravenous

Covered Uses:	All FDA-approved indications not otherwise excluded from Part D. Additional off-label coverage is provided for post bone marrow transplantation, autoimmune hemolytic anemia, Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, corticosteroid treatment resistant dermatomyositis, multifocal neuropathy, myasthenia gravis, and pediatric HIV infection.
Exclusion Criteria:
Required Medical Information:	For Primary immune deficiency and B cell CLL - patient must have history of a recurrent bacterial infection or a single life-threatening bacterial infection AND IgG levels less than or equal to 600 mg/dL. For ITP - platelets must be less than or equal to 30,000/mm3. For bone marrow transplantation (BMT) - BMT must be performed within the previous 100 days AND patient is not also receiving CMV immune globulin
Age Restrictions:
Prescriber Restrictions:
Coverage Duration:	12 months
Other Criteria:

Last Modified on 12/19/2012