interferon gamma-1b — CareFirst (Caremark)

Initial criteria

• Member is prescribed Actimmune to reduce the frequency and severity of infections associated with chronic granulomatous disease (CGD)
• Medication must be prescribed by or in consultation with an immunologist or prescriber who specializes in the management of CGD

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