Displaying 1 - 50 of 56 records found.

Items in this class
Brand Name/Generic Name NDC code Clinical Prior Auth Required PDL Prior Auth Required
BIVIGAM LIQUID 10% VIAL
immun glob G(IgG)/gly/IgA ov50
59730650201 No Yes
CUVITRU 1 GRAM/5 ML VIAL
immun glob G(IgG)/gly/IgA ov50
00944285001 No Yes
CUVITRU 10 GRAM/50 ML VIAL
immun glob G(IgG)/gly/IgA ov50
00944285009 No Yes
CUVITRU 2 GRAM/10 ML VIAL
immun glob G(IgG)/gly/IgA ov50
00944285003 No Yes
CUVITRU 4 GRAM/20 ML VIAL
immun glob G(IgG)/gly/IgA ov50
00944285005 No Yes
CUVITRU 8 GRAM/ 40 ML VIAL
immun glob G(IgG)/gly/IgA ov50
00944285007 No Yes
CYTOGAM 2.5 GM/50 ML VIAL
cytomegalovirus immune globuln
44206053211 No No
FLEBOGAMMA DIF 10% VIAL
imm glob G (IgG)/sorb/IgA 0-50
61953000501 No Yes
FLEBOGAMMA DIF 10% VIAL
imm glob G (IgG)/sorb/IgA 0-50
61953000502 No Yes
FLEBOGAMMA DIF 10% VIAL
imm glob G (IgG)/sorb/IgA 0-50
61953000503 No Yes
FLEBOGAMMA DIF 5% VIAL
imm glob G (IgG)/sorb/IgA 0-50
61953000401 No Yes
FLEBOGAMMA DIF 5% VIAL
imm glob G (IgG)/sorb/IgA 0-50
61953000402 No Yes
FLEBOGAMMA DIF 5% VIAL
imm glob G (IgG)/sorb/IgA 0-50
61953000403 No Yes
FLEBOGAMMA DIF 5% VIAL
imm glob G (IgG)/sorb/IgA 0-50
61953000404 No Yes
FLEBOGAMMA DIF 5% VIAL
imm glob G (IgG)/sorb/IgA 0-50
61953000405 No Yes
GAMMAGARD LIQUID 10% VIAL
immun glob G(IgG)/gly/IgA ov50
00944270002 No No
GAMMAGARD LIQUID 10% VIAL
immun glob G(IgG)/gly/IgA ov50
00944270003 No No
GAMMAGARD LIQUID 10% VIAL
immun glob G(IgG)/gly/IgA ov50
00944270004 No No
GAMMAGARD LIQUID 10% VIAL
immun glob G(IgG)/gly/IgA ov50
00944270005 No No
GAMMAGARD LIQUID 10% VIAL
immun glob G(IgG)/gly/IgA ov50
00944270006 No No
GAMMAGARD LIQUID 10% VIAL
immun glob G(IgG)/gly/IgA ov50
00944270007 No No
GAMMAKED 1 GRAM/10 ML VIAL
immune globul G/gly/IgA avg 46
76125090001 No No
GAMMAKED 10 GRAM/100 ML VIAL
immune globul G/gly/IgA avg 46
76125090010 No No
GAMMAKED 20 GRAM/200 ML VIAL
immune globul G/gly/IgA avg 46
76125090020 No No
GAMMAKED 5 GRAM/50 ML VIAL
immune globul G/gly/IgA avg 46
76125090050 No No
GAMUNEX-C 1 GRAM/10 ML VIAL
immune globul G/gly/IgA avg 46
13533080012 No No
GAMUNEX-C 10 GRAM/100 ML VIAL
immune globul G/gly/IgA avg 46
13533080071 No No
GAMUNEX-C 2.5 GRAM/25 ML VIAL
immune globul G/gly/IgA avg 46
13533080015 No No
GAMUNEX-C 20 GRAM/200 ML VIAL
immune globul G/gly/IgA avg 46
13533080024 No No
GAMUNEX-C 40 GRAM/400 ML VIAL
immune globul G/gly/IgA avg 46
13533080040 No No
GAMUNEX-C 5 GRAM/50 ML VIAL
immune globul G/gly/IgA avg 46
13533080020 No No
HIZENTRA 1 GRAM/5 ML VIAL
immun glob G(IgG)/pro/IgA 0-50
44206045101 No No
HIZENTRA 10 GRAM/50 ML VIAL
immun glob G(IgG)/pro/IgA 0-50
44206045510 No No
HIZENTRA 2 GRAM/10 ML VIAL
immun glob G(IgG)/pro/IgA 0-50
44206045202 No No
HIZENTRA 4 GRAM/20 ML VIAL
immun glob G(IgG)/pro/IgA 0-50
44206045404 No No
HYQVIA 10 GM-800 UNIT PACK
IgG/hyaluronidase,recombinant
00944251202 No Yes
HYQVIA 2.5 GM-200 UNIT PACK
IgG/hyaluronidase,recombinant
00944251002 No Yes
HYQVIA 20 GM-1,600 UNIT PACK
IgG/hyaluronidase,recombinant
00944251302 No Yes
HYQVIA 30 GM-2,400 UNIT PACK
IgG/hyaluronidase,recombinant
00944251402 No Yes
HYQVIA 5 GM-400 UNIT PACK
IgG/hyaluronidase,recombinant
00944251102 No Yes
OCTAGAM 10% VIAL
immun globG(IgG)/malt/IgA ov50
68982085001 No Yes
OCTAGAM 10% VIAL
immun globG(IgG)/malt/IgA ov50
68982085002 No Yes
OCTAGAM 10% VIAL
immun globG(IgG)/malt/IgA ov50
68982085003 No Yes
OCTAGAM 10% VIAL
immun globG(IgG)/malt/IgA ov50
68982085004 No Yes
OCTAGAM 5% VIAL
immun globG(IgG)/malt/IgA ov50
68982084001 No Yes
OCTAGAM 5% VIAL
immun globG(IgG)/malt/IgA ov50
68982084002 No Yes
OCTAGAM 5% VIAL
immun globG(IgG)/malt/IgA ov50
68982084003 No Yes
OCTAGAM 5% VIAL
immun globG(IgG)/malt/IgA ov50
68982084004 No Yes
PRIVIGEN 10% VIAL
immun glob G(IgG)/pro/IgA 0-50
44206043605 No Yes
PRIVIGEN 10% VIAL
immun glob G(IgG)/pro/IgA 0-50
44206043710 No Yes