ATGAM
Generic: lymphocyte immune globulin, anti-thymocyte globulin, equine
250 MG — Solution
Also known as:
ATGAM SOLN 50MG/ML
lymphocyte immune globulin, anti-thymocyte globulin, equine
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Coverage by Insurer
Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Ambetter (Centene)
34 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Enhanced CHF Heart Care Silver $0 Rx Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Silver + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Expanded Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Clear Silver with $0 Insulin Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Expanded Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Silver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Expanded Bronze with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Gold with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver $0 Rx Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Focused Silver with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold with Atrium Health + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Complete Gold | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced Asthma/COPD Care Silver $0 Rx Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Everyday Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Elite Bronze | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Streamlined Silver | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Clear Silver with $0 Insulin Options + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Signature Expanded Bronze + Vision + Adult Dental | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Enhanced CHF Heart Care Silver $0 Rx Options | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
| Streamlined Silver with Atrium Health | Tier 5 - Specialty | ✓ | — | ✓ | PA | QL |
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - 80/20 Plus PPO 2026 | Tier 2 - Non-Preferred Generic | — | — | — | None |
| NC State Health Plan - HDHP 2026 | Tier 2 - Non-Preferred Generic | — | — | — | None |
| NC State Health Plan - 70/30 Standard PPO 2026 | Tier 2 - Non-Preferred Generic | — | — | — | None |