Pharmacy Prior Authorization Criteria

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

1. Actimmune Prescribing Information. Horizon Therapeutics USA, Inc. Deerfield, IL. March 2021.

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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

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