Actimmune (interferon gamma-1b) prior authorization
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This document governs prior authorization and step-edit requests for Actimmune (interferon gamma-1b) for AvMed members, specifying required prescriber signatures, clinical criteria for Chronic Granulomatous Disease and severe malignant osteopetrosis, and documentation needed for approval.
No material clinical or coverage changes in this revision.
Coverage Criteria for Actimmune (interferon gamma-1b)
Initial Therapy d
Covered when ALL of the following are met for the selected diagnosis
checkbox on form
checkboxes on form
documented trial and failure required
checkboxes on form
dosing and duration language on form
Use of samples to initiate therapy does not meet step edit/preauthorization criteria. Providers should not rely on manufacturer or office samples as the start of therapy when submitting a prior authorization or step-edit request for Actimmune, because sample use will not satisfy the document requirements for prior authorization.
Coding and Dosing Information
| J9216 | Actimmune (interferon gamma-1b) |
Provider Requirements and Prior Authorization Steps
Prior authorization required
Prescribers must submit a signed medical prior authorization/step-edit request form faxed to 1-877-535-1391 with required clinical documentation to obtain authorization for Actimmune (J9216).
Step therapy required for CGD
For Chronic Granulomatous Disease (CGD), the form requires documented trial and failure of prophylactic antimicrobials — trimethoprim/sulfamethoxazole (5 mg/kg daily, divided) AND itraconazole (200 mg/day for patients > 50 kg) — before approval.
Required documentation and prescriber signature
Provide a hand-signed prescriber signature and supporting documentation for every clinical criterion checked on the form, including lab results, diagnostic test results, chart notes, and baseline testing where applicable (CBC with differential, platelets, LFTs, electrolytes, BUN, creatinine, urinalysis).
Incomplete documentation may delay or deny authorization
Incomplete, incorrect, or illegible information on the request form or missing documentation supporting checked clinical criteria (labs, diagnostics, chart notes) can delay authorization or result in denial.
Background
Actimmune (interferon gamma-1b) is indicated for Chronic Granulomatous Disease (CGD) and severe malignant osteopetrosis per the prior authorization form. The form specifies that prescribers should be appropriately specialized (e.g., Infectious Disease or Hematology for CGD) and documents diagnostic confirmation and baseline testing before approval.
Diagnostic Criteria and Definitions
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