MICRhoGAM

Generic: Rho(D) immune globulin, human

Prefilled Syringe

Human Immunoglobulin G

Also known as: Rho(D) immune globulin, human
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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.
Source: CMS QHP JSON  ·  Formulary date: Oct 13, 2026  ·  Checked: 20 hours, 9 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Elite + PCP Saver Plus Tier 4 - Non-Preferred — — — None
Silver Classic Tier 4 - Non-Preferred — — — None
Secure Tier 4 - Non-Preferred — — — None
Bronze Classic 4700 Tier 4 - Non-Preferred — — — None
Silver Simple PCP Saver Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes Tier 4 - Non-Preferred — — — None
Bronze Classic Standard Tier 4 - Non-Preferred — — — None
Silver Classic Standard Tier 4 - Non-Preferred — — — None
Gold Classic Standard Tier 4 - Non-Preferred — — — None
Bronze Classic Standard | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Classic Standard | with Atrium Health Tier 4 - Non-Preferred — — — None
Gold Classic Standard | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Simple Chronic Care CKM | with Atrium Health Tier 4 - Non-Preferred — — — None
Secure | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Classic 4700 | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Classic | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Simple PCP Saver | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Simple Diabetes | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Simple Chronic Care CKM | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health Tier 4 - Non-Preferred — — — None
69803NC0010074 Tier 4 - Non-Preferred — — — None
69803NC0010075 Tier 4 - Non-Preferred — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health Tier 4 - Non-Preferred — — — None
69803NC0010076 Tier 4 - Non-Preferred — — — None
69803NC0010077 Tier 4 - Non-Preferred — — — None
69803NC0010078 Tier 4 - Non-Preferred — — — None
69803NC0010079 Tier 4 - Non-Preferred — — — None
69803NC0010080 Tier 4 - Non-Preferred — — — None
69803NC0010081 Tier 4 - Non-Preferred — — — None
69803NC0010082 Tier 4 - Non-Preferred — — — None
69803NC0010083 Tier 4 - Non-Preferred — — — None
69803NC0010084 Tier 4 - Non-Preferred — — — None
69803NC0010085 Tier 4 - Non-Preferred — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision Tier 4 - Non-Preferred — — — None
Bronze Simple Diabetes Tier 4 - Non-Preferred — — — None
Silver Core Plan Tier 4 - Non-Preferred — — — None
Silver Core Plan | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes with Adult Dental & Vision Tier 4 - Non-Preferred — — — None
69803NC0010108 Tier 4 - Non-Preferred — — — None
69803NC0010109 Tier 4 - Non-Preferred — — — None
69803NC0010110 Tier 4 - Non-Preferred — — — None
69803NC0010111 Tier 4 - Non-Preferred — — — None
69803NC0010112 Tier 4 - Non-Preferred — — — None
69803NC0010113 Tier 4 - Non-Preferred — — — None
69803NC0010114 Tier 4 - Non-Preferred — — — None
69803NC0010115 Tier 4 - Non-Preferred — — — None
69803NC0010116 Tier 4 - Non-Preferred — — — None
69803NC0010117 Tier 4 - Non-Preferred — — — None
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health Tier 4 - Non-Preferred — — — None
Bronze Elite + PCP Saver Plus
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Classic
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Secure
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Classic 4700
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Simple PCP Saver
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Classic Standard
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Classic Standard
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Gold Classic Standard
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Classic Standard | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Classic Standard | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Gold Classic Standard | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Simple Chronic Care CKM | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Secure | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Classic 4700 | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Elite + PCP Saver Plus | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Classic | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Simple PCP Saver | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Simple Diabetes | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Simple Chronic Care CKM | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010074
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010075
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010076
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010077
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010078
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010079
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010080
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010081
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010082
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010083
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010084
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010085
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Elite + PCP Saver Plus with Adult Dental & Vision
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Simple Diabetes
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Core Plan
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Core Plan | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes with Adult Dental & Vision
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010108
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010109
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010110
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010111
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010112
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010113
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010114
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010115
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010116
via RhoGAM 		Tier 4 - Non-Preferred — — — None
69803NC0010117
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Bronze Simple Diabetes with Adult Dental & Vision | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
Silver Simple Diabetes with Adult Dental & Vision | with Atrium Health
via RhoGAM 		Tier 4 - Non-Preferred — — — None
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