Actimmune (interferon gamma-1b)
Indications for Prior Authorization
Actimmune (interferon gamma-1b)
-
For diagnosis of Chronic Granulomatous Disease (CGD)
Indicated for reducing the frequency and severity of serious infections associated with Chronic Granulomatous Disease (CGD). -
For diagnosis of Severe Malignant Osteopetrosis (SMO)
Indicated for delaying time to disease progression in patients with severe, malignant osteopetrosis (SMO).
Criteria
Actimmune
Prior Authorization (Initial Authorization)
Length of Approval: 12 Month(s)
- Diagnosis of one of the following:
- Chronic granulomatous disease (CGD)
- Severe, malignant osteopetrosis (SMO)
Actimmune
Prior Authorization (Reauthorization)
Length of Approval: 12 Month(s)
- Patient does not show evidence of progressive disease while on therapy
P & T Revisions
2024-04-03, 2023-04-11, 2022-04-04, 2021-09-27, 2021-05-25, 2021-04-02, 2020-03-03
References
- Actimmune Prescribing Information. Horizon Therapeutics USA, Inc. Deerfield, IL. March 2021.
Revision History
- 2024-04-03: 2024 Annual Review. No criteria changes.
- 2023-04-11: Annual review
- 2022-04-04: Annual review - reformatted criteria without changing clinical intent. Updated background and references.
- 2021-09-27: Addition of EHB formulary to guideline, no changes to criteria
- 2021-05-25: Addition of EHB formulary to guideline, no changes to criteria
- 2021-04-02: Annual Review
- 2020-03-03: Annual reviews
HEALTHY LIVING