- For immune globulin intravenous (including Gamunex-C and Gammagard when used intravenously)
- For the treatment of primary immunodeficiency disorders associated with defects in humoral immunity. These include, but are not limited to, congenital X-linked agammaglobulinemia, common variable immunodeficiency, Wiskott-Aldrich syndrome, and severe combined immunodeficiencies.
- In idiopathic thrombocytopenic purpura (ITP) to rapidly raise platelet counts to prevent bleeding or to allow a patient with ITP to undergo surgery.
- For prevention of bacterial infections in patients with hypogammaglobulinemia and/or recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia (CLL).
- For the prevention of coronary artery aneurysms associated with Kawasaki syndrome.
- For treatment of chronic inflammatory demyelinating polyneuropathy (CIDP).
- For immune globulin subcutaneous (including Gamunex-C and Gammagard when used subcutaneously)
- Treatment of patients with primary immunodeficiency (PID).
Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.