Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Gamunex-C immune globulin(hum),capr(IgG) 1 gram/10 mL (10 %) Solution; 2.5 gram/25 mL (10 %) Solution; 5 gram/50 mL (10 %) Solution; 20 gram/200 mL (10 %) Solution; 10 gram/100 mL (10 %) Solution   Not Applicable Hizentra immune globulin (human) (IgG) 1 gram/5 mL (20 %) Solution; 2 gram/10 mL (20 %) Solution; 4 gram/20 mL (20 %) Solution   Not Applicable HyperRHO S/D rho(D) immune globulin 1,500 unit (300 mcg) Syringe   Not Applicable HyperRHO S/D rho(D) immune globulin 250 unit (50 mcg) Syringe   Not Applicable RhoGam Ultra-Filtered Plus rho(D) immune globulin 1,500 unit (300 mcg) Syringe   Not Applicable WinRho SDF rho(D) immune globulin-maltose 1,500 unit/1.3 mL Solution   Not Applicable WinRho SDF rho(D) immune globulin-maltose 15,000 unit/13 mL Solution; 2,500 unit/2.2 mL Solution; 5,000 unit/4.4 mL Solution   Not Applicable WinRho SDF rho(D) immune globulin-maltose 600 unit/0.5 mL Solution   Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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