SCIG: Hizentra®, Vivaglobin®, Gammagard Liquid®, Gamunex ...

SCIG: Hizentra?, Vivaglobin?, Gammagard Liquid?, Gamunex?-C, Gammaked?, Hyqvia

(immune globulin SQ)

*IH*

Document Number: IH-0059

Last Review Date: 3/29/2016 Date of Origin: 7/20/2010 Dates Reviewed: 09/2010, 12/2010, 03/2011, 06/2011, 09/2011, 12/2011, 03/2012, 06/2012, 09/2012.

12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 09/2014, 12/2014, 03/2015, 06/2015, 09/2015, 12/2015, 3/2016

I. Length of Authorization

Coverage is provided for 6 months and may be renewed for 1 year

II. Dosing Limits

A. Quantity Limit (max daily dose) [Pharmacy Benefit]:

Drug Name

Dose/ week

Dose/28 days

# Vials/28 days

Hizentra

Male: 27 g or 135 mL Male: 108 g or 540 mL Male: 11 x 50 mL Female: 23 g or 115 mL Female: 92 g or 460 mL Female: 10 x 50 mL

Vivaglobin

Discontinued

Discontinued

Discontinued

Gamunex & Male: 24 g or 240 mL Male: 96 g or 960 mL Male: 5 x 200 mL Gammaked Female: 21 g or 210 mL Female: 84 g or 840 mL Female: 9 x 100 mL

Gammagard Male: 24 g or 240 mL Male: 96 g or 960 mL Male: 5 x 200 mL

liquid

Female: 21 g or 210 mL Female: 84 g or 840 mL Female: 3 x 300 mL

HyQvia

Male: 17.25 g or 173 mL Male: 69 g or 690 mL Male: 7 x 100 mL Female: 15 g or 150 mL Female: 60 g or 600 mL Female: 2 x 300 mL

B. Max Units (per dose and over time) [Medical Benefit]: Drug Name Billable units/28 days

Proprietary & Confidential ? 2016 Magellan Health Services, Inc.

Drug Name Billable units/28 days

Hizentra

Male: 1080 Female: 920

Vivaglobin Discontinued

Gamunex & Male: 192 Gammaked Female: 168

Gammagard Male: 192

liquid

Female: 168

HyQvia

Male: 690 Female: 600

III. Initial Approval Criteria

Baseline values for BUN and serum creatinine obtained within 30 days of request; AND

Coverage is provided in the following conditions:

Primary immunodeficiency (PID)/Wiskott - Aldrich syndrome

Such as: x-linked agammaglobulinemia, common variable immunodeficiency, transient hypogammaglobulinemia of infancy, IgG subclass deficiency with or without IgA deficiency, antibody deficiency with near normal immunoglobulin levels) and combined deficiencies (severe combined immunodeficiencies, ataxia-telangiectasia, x-linked lymphoproliferative syndrome) [list not all inclusive]

? Patient's IgG level is ................
................

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