Immune Globulin, subcutaneous (Hizentra, HyQvia, Gamunex-C, Gammagard, Gammaked)

SELF ADMINISTRATION / HOME HEALTH

Indications for Prior Authorization

  • Primary Immunodeficiency disorders
    • congenital agammaglobulinemia
    • X-linked agammaglobulinemia, combined immunodeficiency
    • hypogammaglobulinemia
    • common variable hypogammaglobulinemia/immunodeficiency
    • X-linked immunodeficiency
    • Wiskott-Aldrich syndrome

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:

  • Indications not listed above
  • Isolated IgG4 deficiency
  • Selective IgA deficiency
  • Non-infusion related adverse drug reactions

All of the following must be met as a condition(s) for coverage:

  • History of recurrent bacterial infections; AND
  • Patient did not respond to IgG antibody production after challenge (diphtheria/tetanus toxoids/pneumococcal vaccine); AND
  • Decreased IgG concentrations documented on two or more occasions by an allergist or immunologist; AND
  • Unable to tolerate IVIG therapy infusion-related adverse event (anaphylaxis, aseptic meningitis or limited venous access)

Approval:

Review annually


 

Last review date: September 1, 2014

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