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Immune Globulins Therapy

Page 1 of 43 Coverage Policy Number: 5026 Drug and Biologic Coverage Policy Effective Date .. 3/1/2022 Next Review .. 3/1/2023 Coverage Policy Number .. 5026 Immune Globulin Table of Contents Overview .. 1 Medical Necessity Criteria .. 1 Authorization Duration .. 11 Reauthorization Criteria .. 11 Conditions Not 12 FDA Approved Indications .. 12 Recommended Dosing .. 15 General Background .. 23 Coding/Billing Information .. 37 References .. 40 Related Coverage Resources Eltrombopag Medication Administration Site of Care Recurrent Pregnancy Loss: Diagnosis and Treatment Rituximab for Non-Oncology Indications Romiplostim INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies.

immunosuppression, antiviral treatment) in cancer or solid organ transplant recipients. HIV-infected Children ONE of the following criteria is met: • Primary prophylaxis of bacterial infections when hypogammaglobulinemia (serum IgG < 400 mg/dL) is present • Secondary prophylaxis of frequent recurrent serious bacterial infections

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banfffoundation.org

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