Actimmune (interferon gamma-1b) — United Healthcare
Primary Cutaneous Lymphomas (Mycosis fungoides, Sézary syndrome)
Initial criteria
- Patient has one of the following diagnoses:
- Mycosis fungoides (MF)
- OR Sézary syndrome (SS)
Reauthorization criteria
- Patient does not show evidence of progressive disease while on Actimmune
Approval duration
12 months