interferon gamma-1b — CareFirst (Caremark)
Mycosis Fungoides/Sezary Syndrome
Initial criteria
- Member is prescribed Actimmune for treatment of mycosis fungoides or Sezary syndrome
- Medication must be prescribed by or in consultation with a hematologist or oncologist
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