Immune globulin (IVIG), various brand names

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

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