UnitedHealthcare
Privigen (immun glob G(IgG)-pro-IgA 0-50)
Biological Agents : Biological Agents
  • PID: Immune Globulin:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    Documented inability to mount an immune response: Yes
    Documentation of severe infection despite prophylactic ABX treatment: No
    Documented Serum IgG Level: N/A
    IgG Subclass Level Referencing Standard Deviation Below Age Adjusted Mean: N/A
    Supporting Documentation Requirements: Medical Tests

  • Prior Authorization: PID: Immune Globulin:
    Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

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