Actimmune (interferon gamma-1b subcutaneous injection – Horizon) — Cigna

Initial criteria

• Diagnosis has been established by ONE of the following (i or ii):
• i. Patient has had radiographic (X-ray) imaging demonstrating skeletal features related to osteopetrosis; OR
• ii. Patient has had a molecular genetic test identifying a gene-related pathogenic variant linked to severe, infantile malignant osteopetrosis; AND
• The medication is prescribed by or in consultation with an endocrinologist.

Approval duration

1 year