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

Approved for: 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:

  • All of the following:
    • 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)

Coverage Period

Review annually

Western Health Advantage Pharmacy and Therapeutics Committee

Approved/Revised: September 2014                        Reviewed: