CurrenteternalhealthPolicy 26208

Actimmune (interferon gamma-1b) coverage

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This policy establishes prior authorization criteria for Actimmune injection. Coverage requires documentation of chronic granulomatous disease or severe malignant osteopetrosis, with approval available for continuation of prior therapy.

Policy Summary

Payereternalhealth

PolicyActimmune (interferon gamma-1b) coverage

Policy CodePolicy 26208

Change TypeNo material change

Effective DateNov 1, 2026

Next Review DateN/A

Key ActionSubmit documentation confirming a diagnosis of chronic granulomatous disease or severe malignant osteopetrosis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered diagnostic conditions

12 monthsCoverage duration

RequiredPrior authorization

Not requiredPrerequisite Part D drug

Medical Necessity and Covered Indications

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CurrenteternalhealthPolicy 26208

Actimmune (interferon gamma-1b) coverage

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Policy Summary

Payereternalhealth

PolicyActimmune (interferon gamma-1b) coverage

Policy CodePolicy 26208

Change TypeNo material change

Effective DateNov 1, 2026

Next Review DateN/A

Key ActionSubmit documentation confirming a diagnosis of chronic granulomatous disease or severe malignant osteopetrosis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered diagnostic conditions

12 monthsCoverage duration

RequiredPrior authorization

Not requiredPrerequisite Part D drug

Medical Necessity and Covered Indications

Covered Indications and Product-Specific Medical Necessity Criteria

Coverage is available when the requested product, indication, and all applicable clinical requirements below are met.

Actimmune covered indications: Diagnosis of chronic granulomatous disease (CGD) or severe malignant osteopetrosis (SMO).

Pulmonary hypertension products: For Alyq, symptomatic PAH confirmed by right-heart catheterization or current PAH therapy. For Adempas, either symptomatic PAH meeting the same confirmation/current-therapy pathway or inoperable or persistent/recurrent symptomatic CTEPH, or current CTEPH therapy.

Initial PAH therapy is prescribed by or in consultation with a pulmonologist or cardiologist.

Afinitor indications: SEGA associated with TSC requiring therapeutic intervention; advanced RCC after SUTENT or NEXAVAR trial/failure, contraindication, or intolerance; progressive unresectable, locally advanced, or metastatic pNET; renal angiomyolipoma with TSC; advanced hormone-receptor-positive/HER2-negative breast cancer after FEMARA or ARIMIDEX trial/failure, contraindication, or intolerance; or progressive, well-differentiated, non-functional GI or lung NET that is unresectable, locally advanced, or metastatic.SEGA age at least 1 year

Afinitor Disperz indications: SEGA associated with TSC requiring therapeutic intervention or TSC-associated partial-onset seizures.Age at least 1 year for SEGA; at least 2 years for seizures

Seizure treatment requires neurologist prescribing or consultation.

Migraine prevention: Episodic migraine with at least 4 migraine days per month, or chronic migraine with at least 8 migraine days per month after medication-overuse headache has been considered and potentially offending medication discontinued.Age at least 18 years

Aimovig and Emgality must not be combined with another CGRP inhibitor as specified by the requested indication.

Akeega: Metastatic prostate cancer with deleterious or suspected deleterious BRCA mutation; used with prednisone and a GnRH agent.

Alecensa or Alunbrig: Diagnosis of non-small cell lung cancer; continuation of prior therapy may be approved.

Prolastin-c: Congenital AAT deficiency with emphysema; continued conventional emphysema treatment; qualifying PiZZ, PiZ(null), Pi(null)(null), or other qualifying genotype; and pretreatment serum AAT below 11 µM/L.<11 µM/L, or <80 mg/dL by radial immunodiffusion

Dalfampridine: Multiple sclerosis with documented difficulty walking and either EDSS score 7 or less, or no wheelchair restriction when EDSS is not measured.

Arformoterol: COPD and maintenance treatment of bronchoconstriction, including chronic bronchitis or emphysema.

Arikayce: MAC lung disease; combination antibacterial regimen; and failure to achieve at least two negative sputum cultures after at least 6 consecutive months of multidrug background therapy.

Prescribed by or in consultation with an infectious disease specialist.

Augtyro: Locally advanced or metastatic ROS1 rearrangement-positive NSCLC, or locally advanced, metastatic, or unresectable NTRK-fusion-positive solid tumor that progressed after treatment or has no satisfactory alternative.

Austedo: Chorea associated with Huntington disease, or tardive dyskinesia with persistent symptoms despite dose reduction, tapering, or discontinuation of the offending drug, or when such a trial is inappropriate.

Avmapki Fakzynja: KRAS mutation confirmed by an FDA-approved or CLIA-approved test and prior systemic therapy.

Avtozma and Avtozma SC: Applicable active RA, SJIA, PJIA, GCA, CAR-T-associated CRS, hospitalized COVID-19 requiring systemic corticosteroids and respiratory support, or SSc-ILD pathway, including required conventional or biologic therapy, imaging, specialist, and treatment-setting criteria.

Oncology and hematology indications: Covered product-specific indications include GIST, AdvSM/ISM, qualifying FGFR3-altered urothelial carcinoma, active SLE or lupus nephritis, polycythemia vera or essential thrombocythemia, Ph-positive CML, BRAF-mutated melanoma/colorectal cancer/NSCLC, lymphoma, aTTP, RCC/HCC/DTC or neuroendocrine tumors, MCL/CLL/SLL, thyroid cancer, Gaucher disease, bile-acid synthesis or peroxisomal disorders, AML, iron overload, pheochromocytoma, prostate cancer, basal cell carcinoma, IPF, and qualifying NSCLC biomarkers.

Each product remains subject to its indication-specific disease status, biomarker, age, laboratory, combination, and prior-treatment requirements.

Pulmonary, infectious, neurologic, and metabolic indications: Covered product-specific indications include cystic fibrosis with qualifying Pseudomonas or tolerance findings, invasive aspergillosis or mucormycosis, COPD, MS, partial-onset or syndrome-associated seizures, HAE prophylaxis or acute attacks, cerebrotendinous xanthomatosis, sickle cell disease with recurrent painful crises, Fabry disease, severe eosinophilic asthma, EGPA, HES, breakthrough cancer pain, and growth hormone deficiency or qualifying growth failure.

Product-specific age, specialist, laboratory, prior-treatment, and response criteria apply.

Inflammatory and gastrointestinal indications: Covered product-specific indications include RA, PJIA, PsA, plaque psoriasis, AS, nr-axSpA, ERA, HS, Crohn disease, UC, uveitis, EoE, atopic dermatitis, COPD with type 2 inflammation, bullous pemphigoid, CSU, AFRS, and peptic ulcer disease.

Indication-specific severity, objective findings, prior therapy, specialist, and combination-treatment requirements apply.

Other covered indications: Covered product-specific indications also include BPH, confirmed onychomycosis, toxoplasmosis treatment or prophylaxis, acute agitation associated with schizophrenia or bipolar disorder, glycopyrrolate-treated peptic ulcer disease, neurofibromatosis type 1 with inoperable plexiform neurofibromas, and inability to swallow generic imatinib for Imkeldi.

Continuation of prior therapy: Continuation may be approved when the product-specific covered indication remains applicable and prior therapy is documented.

Initial Authorization Requirements

Initial Therapy Criteria

Initial authorization requires the applicable diagnosis and every criterion in the requested product pathway.

Alyq or Adempas PAH: Symptomatic PAH with right-heart catheterization confirmation or current PAH therapy.

Pulmonologist or cardiologist prescribing or consultation required.

Adempas CTEPH: Inoperable or persistent/recurrent symptomatic CTEPH, or current CTEPH therapy.

Afinitor or Afinitor Disperz: Meet one covered SEGA, TSC seizure, RCC, pNET, renal angiomyolipoma, breast cancer, or GI/lung NET pathway, including age and prior-treatment requirements where applicable.

Aimovig or Emgality: Episodic migraine with at least 4 migraine days monthly; chronic migraine with at least 8 migraine days monthly and medication-overuse assessment; or qualifying episodic cluster headache.Age at least 18 years

Akeega: Metastatic deleterious or suspected deleterious BRCA-mutated prostate cancer, used with prednisone and a GnRH agent.

Alecensa: Diagnosis of NSCLC.

Prolastin-c: Congenital AAT deficiency, emphysema, conventional emphysema treatment, qualifying genotype, and serum AAT below 11 µM/L.<11 µM/L

Dalfampridine: MS, difficulty walking, and EDSS 7 or less or no wheelchair restriction when EDSS is not measured.

Austedo: Huntington disease chorea, or tardive dyskinesia with persistent symptoms after offending-medication reduction, tapering, or discontinuation, or documented inappropriateness of that trial.

Avtozma or Avtozma SC: Meet the requested RA, SJIA, PJIA, GCA, CRS, COVID-19, or SSc-ILD pathway, including required prior therapy, hospitalization, respiratory support, imaging, and specialist criteria.

Ayvakit through Calquence: Meet the requested disease, biomarker, stage, platelet, prior-treatment, combination-treatment, transplant, or specialist pathway for Ayvakit, Balversa, Benlysta, Besremi, Bosulif, Braftovi, Bronchitol, Brukinsa, Cablivi, Cabometyx, or Calquence.

Caplyta through Ctexli: Meet the requested schizophrenia, bipolar depression, MDD, thyroid cancer, CF/Pseudomonas, Gaucher, bile-acid disorder, BPH, onychomycosis, HAE, CLL/SLL, Cosentyx, Cotellic, Cresemba, or cerebrotendinous xanthomatosis pathway.

Daurismo through Dupixent: Meet the requested AML, iron-overload, pheochromocytoma, Dravet, thrombocytopenia/ITP, asthma, COPD, EoE, atopic dermatitis, bullous pemphigoid, CSU, AFRS, or other indication-specific diagnosis, laboratory, age/weight, prior-treatment, and specialist requirements.

Ebglyss through Epidiolex: Meet the requested atopic dermatitis, migraine/cluster headache, PNH/C3G/primary IC-MPGN, inflammatory disease, sickle-cell, ALK-positive NSCLC, chronic HCV, or LGS/Dravet/TSC seizure pathway.

Procrit through Evrysdi: Meet the applicable anemia scenario and laboratory thresholds; metastatic or qualifying locally advanced BCC; prostate cancer; IPF diagnostic and pulmonology criteria; mild-to-moderate AD with topical-therapy history; or SMA genetic, respiratory, motor-assessment, and therapy restrictions.

Fabrazyme through Icatibant: Meet the applicable Fabry, severe eosinophilic asthma, EGPA, HES, breakthrough-cancer-pain/opioid-tolerance, Fintepla seizure, or acute HAE diagnostic and treatment pathway.

Firmagon through Gilotrif: Meet the applicable advanced prostate cancer, relapsed/refractory RCC, metastatic colorectal cancer, immunization, RET-positive cancer, relapsing MS, or EGFR-mutated NSCLC pathway, including required treatment history and biomarkers.

Glatiramer acetate through Humira: Meet the applicable relapsing-MS, peptic-ulcer/acid-suppression, neurofibromatosis, growth-hormone, HER2-mutated NSCLC, or Humira inflammatory bowel, rheumatologic, dermatologic, uveitis, or HS pathway.

Products reviewed for all medically accepted indications: For Hyrnuo, Ibrance, Ibtrozi, Iclusig, Idhifa, Igalmi, Imbruvica, and Imkeldi, document the product-specific diagnosis and required medical information; meet any specified biomarker, prior-treatment, formulation, age, or combination requirement.

Renewal and Continuation Requirements

Continuation and Reauthorization Criteria

Reauthorization requires continued appropriate use and the product-specific response, laboratory, treatment, or prior-therapy criteria below.

Alyq or Adempas: Patient demonstrates positive clinical response to therapy.12-month reauthorization

Aimovig or Emgality: Positive response; decreased acute migraine medication use; no prohibited concurrent CGRP inhibitor; and continued medication-overuse-headache monitoring for chronic migraine.

Prolastin-c: Positive clinical response and continued conventional emphysema treatment.12 months

Dalfampridine: Physician confirms improved walking and the applicable EDSS or wheelchair-use criterion remains met.

Austedo, Avtozma, Benlysta, Bronchitol, Cayston, Ctexli, Roflumilast, Demser, Doptelet, Dulera, Ebglyss, Enbrel, Endari, Esbriet, Eucrisa, Fasenra, Humira, and related products: Patient demonstrates the positive clinical response required for the indication, such as improved symptoms, disease activity, laboratory values, function, joint counts, BSA/SCORAD, pulmonary exacerbations, platelet count, liver function, or sickle-cell complications.

HAE prophylaxis: Positive clinical response and continued avoidance of combination with another approved HAE prophylaxis treatment.12 months

Cosentyx and Cosentyx IV: Document indication-specific improvement from baseline, including joint counts, symptoms, BSA, disease activity, inflammatory markers, function, axial status, abscesses, nodules, sinus tracts, scarring, pain, or suppuration.12-month reauthorization

Procrit: Meet the applicable disease-specific continuation pathway with positive response and required hemoglobin/hematocrit, ongoing chemotherapy or ribavirin, and other laboratory criteria.

Evrysdi: Positive clinical response; no concomitant chronic SMN-modifying therapy; and applicable gene-therapy history and inadequate-response documentation.12 months

Fabrazyme: Positive clinical response and no combination with another drug used for Fabry disease.12 months

Icatibant: Positive clinical response and no concomitant use of another approved acute HAE treatment.12 months

Fingolimod or glatiramer acetate: Positive clinical response, neurologist prescribing or consultation, and no combination with another MS disease-modifying therapy.12 months

Glycopyrrolate tablets: Persistent or recurrent peptic ulcer, required PPI or H2-receptor antagonist therapy, reduced symptoms, and gastroenterology prescribing or consultation.3 months

Growth hormone: For pediatric indications, expected adult height has not been attained and the height goal remains applicable; for AGHD or IGHDA, an IGF-1/somatomedin C level was documented within the prior 12 months.12 months

Products requiring continuation of prior therapy: For Alunbrig, Augtyro, Avmapki Fakzynja, Afinitor, Afinitor Disperz, Akeega, Alecensa, oncology products, Epidiolex, Fintepla, and the listed products reviewed only for continuation, continuation of prior therapy is documented and the covered indication remains applicable.

Product-specific continuation review: For Hyrnuo, Ibrance, Ibtrozi, Iclusig, Idhifa, Igalmi, Imbruvica, and Imkeldi, continuation of prior therapy is documented together with the product-specific diagnosis and required medical information.

Prerequisite and Prior-Treatment Requirements

Product	Indication or use	Required prerequisite or step therapy	Failure, contraindication, or intolerance requirement	Minimum duration or quantity
Afinitor	Renal cell carcinoma	SUTENT (sunitinib) or NEXAVAR (sorafenib)	Trial and failure, contraindication, or intolerance	Not specified
Afinitor	Advanced hormone receptor-positive, HER2-negative breast cancer	FEMARA (letrozole) or ARIMIDEX (anastrozole)	Trial and failure, contraindication, or intolerance	Not specified
Augtyro	All covered indications	A prerequisite Part D drug	Not specified	Not specified
Avmapki Fakzynja	All covered indications	A prerequisite Part D drug	Not specified	Not specified
Avtozma IV	Rheumatoid arthritis	Two of: Enbrel, a formulary adalimumab product, Orencia, Rinvoq, or Xeljanz/Xeljanz XR	Trial and failure, contraindication, or intolerance; prescriber attestation may establish that a trial is inappropriate	Two therapies
Avtozma IV	Systemic juvenile idiopathic arthritis	NSAID or systemic glucocorticoid	Trial and failure, contraindication, or intolerance	NSAID: at least 1 month; systemic glucocorticoid: at least 2 weeks
Avtozma IV	Polyarticular juvenile idiopathic arthritis	Two of: Enbrel, a formulary adalimumab product, Orencia, Rinvoq/LQ, or Xeljanz	Trial and failure, contraindication, or intolerance; prescriber attestation may establish that a trial is inappropriate	Two therapies
Avtozma SC	Rheumatoid arthritis	Two of: Enbrel, a formulary adalimumab product, Orencia, Rinvoq, or Xeljanz/Xeljanz XR	Trial and failure, contraindication, or intolerance; prescriber attestation may establish that a trial is inappropriate	Two therapies
Avtozma SC	Systemic juvenile idiopathic arthritis	NSAID	Trial and failure, contraindication, or intolerance	At least 1 month at the maximally tolerated dose
Avtozma SC	Polyarticular juvenile idiopathic arthritis	Two of: Enbrel, a formulary adalimumab product, Orencia, Rinvoq/LQ, or Xeljanz	Trial and failure, contraindication, or intolerance; prescriber attestation may establish that a trial is inappropriate	Two therapies
Balversa	Locally advanced or metastatic urothelial carcinoma	Prior systemic therapy and PD-1 or PD-L1 inhibitor therapy, or documentation that the patient is not a candidate	Disease progression on or after at least one systemic therapy line; PD-1/PD-L1 therapy may be unsuitable	At least 1 systemic therapy line
Besremi	High-risk polycythemia vera	Hydroxyurea	Inadequate response, contraindication, or intolerance	Not specified
Besremi	Essential thrombocythemia	Required prior therapy	Inadequate response	Not specified
Braftovi	Colorectal cancer	Erbitux (cetuximab) plus prior therapy or fluorouracil-based chemotherapy	Prior therapy required unless used with fluorouracil-based chemotherapy	Not specified
Brukinsa	Mantle cell lymphoma	Prior therapy	Prior treatment required	At least 1 prior therapy
Brukinsa	Marginal zone lymphoma	Prior anti-CD20-based regimen	Relapsed or refractory disease; prior regimen required	At least 1 prior anti-CD20 regimen
Brukinsa	Follicular lymphoma	Prior systemic therapy; use with Gazyva	Relapsed or refractory disease	At least 2 prior systemic therapy lines
Cabometyx	Hepatocellular carcinoma	NEXAVAR (sorafenib)	Trial and failure, contraindication, or intolerance	Not specified
Cabometyx	Differentiated thyroid cancer	Prior VEGFR-targeted therapy, such as Lenvima or NEXAVAR	Disease progression; radioactive-iodine refractory or ineligible	Not specified
Cabometyx	Pancreatic or extra-pancreatic neuroendocrine tumors	Previous treatment, such as octreotide, lanreotide, or chemotherapy	Previous treatment required	Not specified
Calquence	Mantle cell lymphoma, treatment-naive pathway	Bendamustine plus rituximab	No prior MCL therapy and patient ineligible for autologous HSCT	No prior therapy
Calquence	Mantle cell lymphoma, previously treated pathway	Prior MCL therapy	Prior therapy required	At least 1 prior therapy
Caplyta	Schizophrenia	Two listed generic atypical antipsychotics	Trial and failure, contraindication, or intolerance	Two agents
Caplyta	Bipolar depression	Quetiapine IR/ER or olanzapine	Trial and failure, contraindication, or intolerance	Not specified
Caplyta	Major depressive disorder	Aripiprazole and quetiapine IR/ER	Trial and failure, contraindication, or intolerance	Both agents
Tadalafil	Benign prostatic hyperplasia	An alpha-blocker or 5-alpha reductase inhibitor	Trial and failure, contraindication, or intolerance	Not specified
Ciclopirox	Fingernail or toenail onychomycosis	Oral terbinafine	Trial and failure, contraindication, or intolerance	Fingernails: minimum 6-week supply; toenails: minimum 12-week supply
Cobenfy	All covered indications	Two listed oral generic formulary atypical antipsychotics	Intolerance	Two agents
Copiktra	Relapsed or refractory CLL/SLL	Prior CLL/SLL therapies	Trial and failure, contraindication, or intolerance	At least 2 prior therapies
Cosentyx	Plaque psoriasis	One topical corticosteroid, vitamin D analog, tazarotene, or calcineurin inhibitor	Trial and failure, contraindication, or intolerance	At least 4 weeks
Cosentyx	Ankylosing spondylitis	One NSAID at the maximally tolerated dose	Trial and failure, contraindication, or intolerance	At least 1 month
Cosentyx	nr-axSpA or enthesitis-related arthritis	Two NSAIDs at maximally tolerated doses	Trial and failure, contraindication, or intolerance	At least 1 month
Cosentyx IV	Psoriatic arthritis	Two listed formulary alternatives	Trial and failure, contraindication, or intolerance, unless continuation of prior therapy	Not specified
Cosentyx IV	Ankylosing spondylitis	Two listed formulary alternatives	Trial and failure, contraindication, or intolerance, unless continuation of prior therapy	Not specified
Cosentyx IV	nr-axSpA	Cosentyx SC and Rinvoq	Trial and failure, contraindication, or intolerance, unless continuation of prior therapy	Both alternatives
Cyclobenzaprine	All covered indications	A prerequisite Part D drug	Not specified	Not specified
Roflumilast	COPD	Two prior COPD therapies	Trial and failure, intolerance, or contraindication	Two therapies
Demser	Preoperative pheochromocytoma preparation	An alpha-adrenergic blocker and a beta-adrenergic blocker	Trial and failure, contraindication, or intolerance to both	Not specified
Doptelet	Immune thrombocytopenia	A corticosteroid, immunoglobulin, or splenectomy	Trial and failure, contraindication, or intolerance	At least 1 therapy
Dulera	Asthma	Breo Ellipta	Trial, failure, contraindication, or intolerance	Not specified
Dupixent	CRSwNP	Intranasal corticosteroid	Inadequate response, contraindication, or intolerance	At least 2 months
Dupixent	Asthma	Age-appropriate inhaled corticosteroid and additional controller, or ICS/LABA combination	Required therapy may be excepted for contraindication or intolerance	Not specified
Dupixent	Eosinophilic esophagitis	Proton-pump inhibitor or topical esophageal corticosteroid	Trial and failure, contraindication, or intolerance	At least 8 weeks
Dupixent	Atopic dermatitis	Topical corticosteroid, pimecrolimus, tacrolimus ointment, or crisaborole	Failure, contraindication, or intolerance	Usually at least 30 days; 14 days for topical corticosteroids
Dupixent	COPD	Maximally tolerated triple therapy; LAMA plus LABA if ICS is contraindicated	ICS may be omitted for contraindication	Not specified
Ebglyss	Moderate-to-severe atopic dermatitis	Medium- or higher-potency topical corticosteroid, pimecrolimus, tacrolimus ointment, or crisaborole	Failure, contraindication, or intolerance	Usually at least 30 days; 14 days for topical corticosteroids
Empaveli	C3G or primary IC-MPGN	ACE inhibitor, ARB, or SGLT2 inhibitor	Maximally tolerated therapy must be used before initiation and continued for renewal	At least 12 weeks
Enbrel	Rheumatoid arthritis	Methotrexate, leflunomide, or sulfasalazine	Failure, contraindication, or intolerance	At least 3 months
Enbrel	Polyarticular juvenile idiopathic arthritis	Leflunomide or methotrexate	Failure, contraindication, or intolerance	At least 6 weeks
Enbrel	Ankylosing spondylitis	One NSAID at the maximally tolerated dose	Failure, contraindication, or intolerance	At least 1 month
Enbrel	Plaque psoriasis	Appropriate topical therapy	Failure, contraindication, or intolerance	Usually at least 30 days; 14 days for topical corticosteroids
Epidiolex	Lennox-Gastaut syndrome	Two formulary anticonvulsants, such as topiramate, lamotrigine, or valproate	Trial, contraindication, or intolerance	Two agents
Eucrisa	Atopic dermatitis	One prescription-strength topical corticosteroid	Trial and failure, contraindication, or intolerance; not required for sensitive areas such as the face, axillae, or groin	Not specified
Fasenra	Severe eosinophilic asthma	Age-appropriate inhaled corticosteroid and additional controller, or applicable ICS/LABA combination	Required unless contraindicated or intolerable	Not specified
Fasenra	EGPA	Corticosteroid therapy	Required unless contraindicated or intolerable	Not specified
Fasenra	HES	Corticosteroid or cytotoxic/immunosuppressive therapy	Trial and failure, contraindication, or intolerance	Not specified
Fotivda	Relapsed or refractory advanced renal cell carcinoma	At least two prior systemic therapies	Prior therapies required	At least 2 therapies
Fruzaqla	Metastatic colorectal cancer	Fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy plus anti-VEGF therapy; RAS wild-type also requires anti-EGFR therapy plus Lonsurf or Stivarga	Prior treatment required	Not specified
Gilotrif	Advanced or metastatic NSCLC	First-line qualifying EGFR-mutated pathway or post-platinum pathway	Applicable treatment-history requirement	Not specified
Humira	Rheumatoid arthritis	Methotrexate, leflunomide, or sulfasalazine	Failure, contraindication, or intolerance	At least 3 months
Humira	Polyarticular juvenile idiopathic arthritis	Leflunomide or methotrexate	Failure, contraindication, or intolerance	At least 6 weeks
Humira	Plaque psoriasis	Corticosteroid, vitamin D analog, tazarotene, or calcineurin inhibitor	Failure, contraindication, or intolerance	Usually at least 30 days; 14 days for topical corticosteroids
Humira	Ankylosing spondylitis	One NSAID at the maximally tolerated dose	Failure, contraindication, or intolerance	At least 1 month
Glycopyrrolate tablets	Peptic ulcer disease	Concomitant PPI; if contraindicated or intolerable, an H2-receptor antagonist	PPI contraindication or intolerance required when using H2-receptor antagonist instead	Not specified
Hyrnuo	Locally advanced or metastatic non-squamous NSCLC	A prerequisite Part D drug	Prior systemic therapy also required	Not specified
Igalmi	Acute agitation associated with schizophrenia or bipolar I/II disorder	A prerequisite Part D drug and acute-agitation products	Trial and failure, contraindication, or intolerance to at least two acute-agitation products	At least 2 products
Imbruvica	All covered indications	A prerequisite Part D drug	For cGVHD, trial and failure of one or more systemic therapy lines	At least 1 systemic therapy line for cGVHD

Actimmune (interferon gamma-1b) coverage

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Medical Necessity and Covered Indications

Actimmune (interferon gamma-1b) coverage

Sign up for eternalhealth Policy 26208 alerts

Medical Necessity and Covered Indications

Initial Authorization Requirements

Renewal and Continuation Requirements

Prerequisite and Prior-Treatment Requirements

Clinical Thresholds and Quantitative Requirements

Prior Authorization and Submission Requirements

Clinical and Policy Definitions

Policy Scope and Specialty-Drug Context

Administration and Site-of-Care Requirements