- Quantity Limit: limit maximum 3 EA PER fill retail
- 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
- PA Required
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