No prior authorization required for:

• Emergency room
• Inpatient
• Skilled nursing facility
  
  

For further information, please see the Injectable Drugs page

Code(s)

• Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg: J1561
• Immune globulin, lyophilized (e.g., powder), 500 mg IV: J1566 
• Octagam immune globulin injection, intravenous, non-lyophilized (e.g. liquid), 500 mg: J1568
• Gammagard liquid, non-lyophilized, 500 mg: J1569
• Gammagard SD: J1599 
• Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg: J1572
• Immune globulin, 100 mg subcutaneous: 90283
• Privigen, intravenous, non-lyophilized (e.g., liquid), 500 mg: J1459
• Vivaglobin, (SClg) 100 mg subcutaneous: J1562/ 90284
• Bivigam, 500 mg: J1556
• Gammaplex, intravenous, non-lyophilized (e.g., liquid), 500 mg: J1557
• Hizentra, 100 mg: J1559
• HyQvia: J1575

Benefit: Medical

Notes:

• Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg Use for: Gammar-P, Panglobulin, Polygam, Carimune, Gammagard S/D 
• Injection, immune globulin/hyaluronidase, 100 mg