Immune Globulins Subcutaneous
| Covered Uses: | All FDA-approved indications not otherwise excluded from Part D |
| Exclusion Criteria: | |
| Required Medical Information: | For Primary immune deficiency - 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 |
| Age Restrictions: | |
| Prescriber Restrictions: | |
| Coverage Duration: | 12 months |
| Other Criteria: | |
| Excluded Drug Criteria: |
Last Modified on 12/19/2012