CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Actimmune (interferon gamma-1b) coverage

Defines coverage, prescriber requirements, indications, and authorization durations for Actimmune for members of Neighborhood Health Plan of Rhode Island when approval criteria are met.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyActimmune (interferon gamma-1b) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for covered indications; authorizations may be granted for up to 12 months and reauthorization requires evidence of benefit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Covered indications (FDA + compendial)

12 monthsTypical authorization duration

3Required prescriber specialties listed

Coverage Criteria for Actimmune (interferon gamma-1b)

Covered Indications and Conditions

Covered when ALL of the following are met:

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FDA indications: Member has one of the FDA‑approved indications: (1) chronic granulomatous disease (to reduce the frequency and severity of serious infections), OR (2) severe, malignant osteopetrosis (to delay time to disease progression).

source: chunk 1

Compendial use: Member has mycosis fungoides/Sezary syndrome when supported by compendia (covered compendial use).

source: chunk 2

Exclusions and approval criteria: All approval criteria must be met and the member must have no exclusions to the prescribed therapy (other indications are considered experimental/investigational and not medically necessary).

source: chunk 2

Authorization and Reauthorization

Authorization and continuation rules

Initial authorization: Authorization of 12 months may be granted for each covered indication: chronic granulomatous disease, severe malignant osteopetrosis, or mycosis fungoides/Sezary syndrome.12 months

source: chunks 4-6

Continuation of therapy: Reauthorization for 12 months may be granted when members are experiencing benefit from therapy as evidenced by disease stability or disease improvement.12 months

source: chunk 7

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization and Duration

Prior authorization is required for Actimmune (interferon gamma-1b). Authorization may be granted for up to 12 months for covered indications (e.g., chronic granulomatous disease, severe malignant osteopetrosis, mycosis fungoides/Sezary syndrome). Reauthorization (continuation of therapy) requires documentation of clinical benefit such as disease stability or improvement.

Authorization duration: up to 12 months
Covered indications: see policy indications (Chronic Granulomatous Disease; Severe Malignant Osteopetrosis; Mycosis Fungoides/Sezary Syndrome)
Reauthorization requires evidence of benefit (disease stability or improvement)

Documentation Required

Required Documentation for Approval and Reauthorization

Prescribers must submit documentation supporting that the member meets the approval criteria for the requested indication and, for reauthorization, objective evidence of benefit from therapy.

Provide clinical notes, diagnostic test results, and treatment history demonstrating criteria are met
For continuation, include assessments showing disease stability or improvement

Denial Risk

Denial Triggers

Therapy may be denied if required approval criteria are not met or if the member has exclusions to the prescribed therapy.

Denial triggers: failure to meet indication-specific criteria
Denial triggers: inadequate documentation of benefit for reauthorization
Denial triggers: member exclusions to the prescribed therapy

Note

Provider Responsibilities

Providers should be aware of these authorization and documentation requirements and submit complete supporting information at the time of the initial prior authorization request and for any reauthorization request to avoid delays or denials.

Definitions and Compendial Uses

Compendial Uses — Definition and Examples

DefinitionCompendial use: indications supported by compendia such as NCCN (example: mycosis fungoides/Sezary syndrome).

Example covered compendial indicationMycosis fungoides/Sezary syndrome (listed as a covered compendial use).

ScopeCompendial uses are considered covered when supported by recognized compendia; other non‑compendial uses are considered experimental/investigational and not medically necessary.