Interferon Gamma-1b (Actimmune®)

Actimmune (interferon gamma‑1b) is covered only for its FDA‑approved uses—reducing serious infections in chronic granulomatous disease (CGD) and delaying progression in severe, malignant osteopetrosis—and is excluded for all other indications. Coverage requires diagnostic documentation (molecular genetic confirmation for CGD; radiographic evidence or molecular genetic confirmation for osteopetrosis), prescription by or consultation with an immunologist for CGD or an endocrinologist for osteopetrosis, adherence to the specified subcutaneous dosing (50 mcg/m2 three times weekly if BSA >0.5 m2; 1.5 mcg/kg three times weekly if BSA ≤0.5 m2), and is authorized for 12 months.

"Reducing the frequency and severity of serious infections associated with chronic granulomatous disease (CGD)"

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