Varicella Zoster Immune Globulin (Varizig) Coverage Criteria
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Governs coverage and prior authorization requirements for varicella zoster immune globulin (Varizig) for CareOregon members, focusing on high-risk exposures and outpatient medical benefit use.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy
Covered when ALL of the following are met per the decision flow:
Initial diagnosis and timing
- High-risk categories: Member is in one of the following high-risk categories: immunocompromised children and adults; newborns of mothers with varicella before or after delivery; premature infants, neonates, and infants < 1 year; adults without evidence of immunity; pregnant woman.
If yes, approve one dose; if no, do not approve.
Do not approve varicella zoster immune globulin (Varizig) when the documented exposure did not occur within the last 4 days or the member is not in one of the listed high-risk categories. The policy decision flow requires that the member was diagnosed with chickenpox and exposure be within 4 days; if either condition is not met, the request should be denied.
Use of Varizig is not approved when the coverage criteria are not met — for example, when exposure occurred more than 4 days previously or when the member is not in a specified high-risk group. In these situations the policy states: do not approve.
Coding
Provider Actions & Requirements
Prior authorization required
Prior authorization is required for outpatient administration of varicella zoster immune globulin (Varizig).
Outpatient nonformulary — obtain PA
Varizig is listed as nonformulary for the outpatient benefit and PA is required on the medical benefit; ensure PA is obtained before outpatient administration.
Required documentation for PA
Document that the request is for outpatient medical benefit use and include clinical evidence supporting exposure timing and high-risk status; note that the product is nonformulary for the outpatient benefit.
- Record that exposure occurred within the last 4 days
- Document member diagnosis of chicken pox
- Document which high-risk category applies (immunocompromised status, newborn of affected mother, premature/infant <1 year, adult without immunity, or pregnant woman)
Denial triggers — timing, diagnosis, or risk category
Do not approve if the member was not diagnosed with chicken pox, the exposure did not occur within the last 4 days, or the member is not in one of the listed high‑risk categories.
- Exposure > 4 days from request
- Member not diagnosed with chicken pox
- Member not in a listed high‑risk category (immunocompromised; newborn of mother with varicella before/after delivery; premature infants, neonates, infants <1 year; adults without evidence of immunity; pregnant women)
Definitions
Background
Varicella zoster immune globulin (Varizig) is intended for post-exposure prophylaxis to reduce the severity of varicella (chickenpox) in individuals at increased risk of severe disease. The policy prioritizes administration for specific high-risk categories, including immunocompromised children and adults; newborns of mothers with varicella before or after delivery; premature infants, neonates, and infants < 1 year; adults without evidence of immunity; and pregnant women. Consideration for Varizig requires that the member was diagnosed with chickenpox and that exposure occurred within the prior 4 days; if these conditions are satisfied and the member is in a high-risk category, approve one dose.
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