Alfa Interferons
| Covered Uses: | All FDA approved indications not otherwise excluded from Part D. Additional off-label uses covered are Essential thrombocythemia, Philadelphia chromosome (Ph) positive chronic phase myelogenous leukemia (CML) in a patient who is minimally pretreated (e.g., within 1 year of diagnosis), multiple myeloma and Renal cell carcinoma. |
| Exclusion Criteria: | For chronic hepatitis C: contraindications such as decompensated liver disease or when used in combination with another interferon product. |
| Required Medical Information: | For Hepatitis C: quantifiable hepatitis C viral level. For Kaposi sarcoma: T cell count is greater than or equal to 400/mm3 or in the absence of an opportunistic infection. |
| Age Restrictions: | |
| Prescriber Restrictions: | |
| Coverage Duration: | 12 months |
| Other Criteria: | For treatment of condylomata acuminata: at least ONE conventional therapy such as, (but not limited to) topical imiquimod (Aldara), podofilox (Condylox) or liquid nitrogen cryotherapy, has failed to treat the patient. |
Last Modified on 12/19/2012