' Gamunex-C
Immune System Modulators
Immune Globulin

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   nonform.gif (625 bytes)

priorauth.gif (377 bytes) mo.gif sp.gif (377 bytes)

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)

© 2002 Managed Markets Insight and Technology, LLC. All Rights Reserved