Interferon Gamma-1b (Actimmune)

Actimmune (interferon gamma‑1b) is covered only for its FDA‑approved indications—reducing infections in chronic granulomatous disease (CGD) and delaying progression of severe malignant osteopetrosis—and is not covered for non‑FDA uses. Coverage requires diagnostic confirmation (molecular genetic testing for CGD; radiographic X‑ray or molecular genetic confirmation for osteopetrosis), prescription or consultation by a specialist (immunologist for CGD; endocrinologist for osteopetrosis), documentation of BSA/weight to support subcutaneous dosing three times weekly per the BSA/weight table, and is authorized for up to 12 months with clinical records for reauthorization.

"For Severe, malignant osteopetrosis: Documentation that Actimmune is prescribed by, or in consultation with, an endocrinologist."

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