Health Net
Xembify (immune globulin,gamma(IgG)klhw)
Biological Agents : Biological Agents
  • Prior Authorization: PID: Immune Globulin:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • PID: Immune Globulin:
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Immunologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    Documented inability to mount an immune response: Yes
    Documentation of severe infection despite prophylactic ABX treatment: Yes
    Documented Serum IgG Level: N/A
    IgG Subclass Level Referencing Standard Deviation Below Age Adjusted Mean: N/A

  • Step Therapy: PID: Immune Globulin:
    ST Single Brand

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