Interferons

Drug - Interferons - Alferon N (Interferon Alfa-n 3) Actimmune (Interferon Gamma-1 b)

February 2007

Therapeutic area - Interferons

Alferon N (Interferon Alfa-n 3)

Diagnosis - Condylomata acuminata (genital warts)
Document treatment plan - Recommended dose is injections up to 0.5ml twice weekly for 8 weeks
Document unsuccessful trials - Must have had an unsuccessful trial of trichloroacetic acid, podophyllin resin, surgical removal, laser treatments or cryotherapy

Diagnosis - Severe malignant osteopetrosis
Frequent and severe chronic infections associated with granulomatous disease
For the initial authorization request, document the number of serious infections and hospital admissions in the past year. If the recipient has the diagnosis of granulomatous disease but has had no serious infections that required hospitalization, deny the prior authorization. If the recipient has the diagnosis of severe malignant osteopetrosis, no hospitalizations or infections are necessary.
For subsequent authorizations, the recipient does not have to show a continuing need for hospitalizations. (If the drug is working well, the number of hospitalizations should go down.)
Document treatment plan – Recommended dose is subcutaneous injections up to 3 times a week for either diagnosis
Approve for up to 1 year. Total number of fills should not exceed 12, once per month.

MHCP Provider Call Center 651-431-2700 or 800-366-5411