Actimmune — CareFirst (Caremark)
Severe, Malignant Osteopetrosis (SMO)
Initial criteria
- Member is prescribed Actimmune to delay time to disease progression in patients with severe, malignant osteopetrosis (SMO)
- Medication must be prescribed by or in consultation with an endocrinologist
Reauthorization criteria
- Member is experiencing benefit from therapy as evidenced by disease stability or disease improvement
- Member continues to meet the indication listed in the coverage criteria
Approval duration
12 months