CurrentMass General Brigham Health PlanPolicy N/A

GamaSTAN (immune globulin) — Prior Authorization and Coverage Criteria

Defines prior authorization, coverage criteria, and quantity/benefit handling for GamaSTAN (immune globulin) for Mass General Brigham Health Plan members across pharmacy and medical benefits, including specialty pharmacy designation. Affects providers requesting authorization for prophylactic use (hepatitis A, measles, varicella, rubella).

Policy Summary

PayerMass General Brigham Health Plan

PolicyGamaSTAN (immune globulin) — Prior Authorization and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01/01/2024

Next Review DateN/A

Key ActionObtain prior authorization for GamaSTAN; initial approvals are for 1 month and continuation requests must meet initial authorization criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 monthinitial approval duration

10 daysvaricella exposure interval

2 weekshepatitis A exposure interval

6 days?measles exposure interval

GamaSTAN Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Hepatitis A Prophylaxis

Prophylaxis of hepatitis A — Authorization may be granted when ONE of the following criteria is met:

Hepatitis A prophylaxis criteria: Member was exposed to hepatitis A virus within the past 2 weeks (eg, household contact, sexual contact; and child care center or classroom contact with an infected person).<=2 weeks since exposure

Examples of exposure enumerated in document

High-risk hepatitis A exposure: Member is at high risk for hepatitis A exposure (examples of populations at high risk include travelers to or workers in countries of high endemicity and illicit drug users).

Listed as alternative qualifying criterion

Measles (Rubeola) Prophylaxis

Prophylaxis of measles (rubeola) — Authorization may be granted when the following criterion is met:

Measles prophylaxis criteria: Member is unvaccinated and has not had measles previously and was exposed to measles within the past interval referenced in the document (per source).exposure within specified interval per source

Document text truncated; refers to ACIP guidance for exact interval

Varicella Prophylaxis

Prophylaxis of varicella — Authorization may be granted when ALL of the following are met:

Varicella prophylaxis criteria: Member was exposed to varicella within the past 10 days.<=10 days since exposure

Required time window for postexposure prophylaxis

Varicella prophylaxis criteria: Varicella‑zoster immune globulin (eg, Varizig) is not available.

Availability of specific product must be confirmed

Varicella prophylaxis criteria: Member is at high risk for severe varicella (eg, immunocompromised persons, newborns/infants, pregnant women).

High‑risk status required

Rubella Prophylaxis

Prophylaxis of rubella — Authorization may be granted when ALL of the following are met:

Rubella prophylaxis criteria: Member was recently exposed to rubella.recent exposure

Timeframe described in source as 'recent'

Rubella prophylaxis criteria: Member is currently pregnant.

Policy targets pregnant women after rubella exposure

Continuation of Therapy

Continuation criteria: All members (including new members) requesting authorization for continuation of therapy must meet all initial authorization criteria.

Continuation requires meeting initial criteria

All indications for GamaSTAN other than the listed FDA-approved prophylactic uses are considered experimental/investigational and not medically necessary.

Use of GamaSTAN for indications other than the FDA-approved prophylactic uses—pre- or post-exposure prophylaxis of hepatitis A, postexposure prophylaxis/modification of measles (rubeola), postexposure prophylaxis of varicella in immunosuppressed patients when varicella-zoster immune globulin is not available, and postexposure prophylaxis of rubella during pregnancy—is not covered and is considered experimental/investigational.

Prior Authorization, Specialty Handling, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for GamaSTAN®. Initial approvals are granted for 1 month. Continuation requests (including for members new to the plan who are currently receiving treatment) must meet the initial authorization criteria.

Initial approvals: 1 month
Continuation requests must meet all initial authorization criteria

Note

Specialty Pharmacy Requirement

These medications have been designated specialty and must be filled at a contracted specialty pharmacy. Contact the specialty pharmacy team for prior authorization and dispensing information.

Specialty medications: Medical and Specialty Medications — Phone: 877-519-1908; Fax: 855-540-3693
Non-specialty medications: Phone: 800-711-4555

Step Therapy

Step Therapy and Specialty Handling

Step therapy / specialty handling applies: these products are specialty-designated with quantity limits under the pharmacy benefit. Providers must follow step therapy and quantity limit rules and use the contracted specialty pharmacy for dispensing when applicable.

Designation: Specialty — must be filled at a contracted specialty pharmacy
Program types noted: Quantity Limit; Step Therapy
Contact for prior authorization and benefit questions: Specialty team Phone: 877-519-1908

Denial Risk

New Member Incoming-Treatment Requirement

Members new to the plan who are currently receiving the requested medication may be authorized; members new to the plan who are not currently receiving the medication may be denied. Authorization does not apply when product was obtained only as samples or via manufacturer patient assistance programs.

New member incoming-treatment: Authorization may be granted only if member is currently receiving treatment with the requested medication
Exclusion: authorization not granted for members obtaining product solely as samples or through manufacturer's patient assistance programs

OpenPayer

GamaSTAN (immune globulin) — Prior Authorization and Coverage Criteria

GamaSTAN Coverage Criteria

Prior Authorization, Specialty Handling, and Provider Requirements

FDA-Approved Indications and Key Definitions

Clinical Background