interferon gamma-1b — CareFirst (Caremark)

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