01Claims for Actimmune (interferon gamma-1b) need documentation that the drug is prescribed by or in consultation with an immunologist or a prescriber who specializes in CGD (chronic granulomatous disease), an endocrinologist (severe malignant osteopetrosis), or a hematologist or oncologist (mycosis fungoides/Sezary syndrome).
02Claims for Actimmune for any other indication will not be covered, because Aetna considers those indications experimental, investigational, or unproven.
03Continued Actimmune therapy is covered for members experiencing benefit, as evidenced by disease stability or disease improvement.
04Claims for peginterferon alfa-2a (Pegasys) need documentation that the member meets the initial criteria for the indication billed.
05Hepatitis B treatment with Pegasys is covered for up to a total of 48 weeks, and treatment for more than 48 weeks is considered experimental, investigational, or unproven.
06Claims for ropeginterferon alfa-2b-njft (Besremi) for essential thrombocythemia, myelofibrosis, systemic mastocytosis, mycosis fungoides/Sezary syndrome, primary cutaneous CD30+ T-cell lymphoproliferative disorders, or adult T-cell leukemia/lymphoma need documentation that peginterferon alfa-2a (Pegasys) is unavailable.
07For essential thrombocythemia, Besremi is also covered after an inadequate response or loss of response to prior cytoreductive therapy such as anagrelide, hydroxyurea, or Pegasys.
08Aetna considers all other indications for Pegasys and Besremi experimental, investigational, or unproven, so claims for those indications will not be covered.
09Aetna considers the Biojector 2000 needle-free injection system a medically necessary acceptable alternative to conventional needles and syringes for members with exacerbating-remitting MS who cannot safely use needles for self-injection due to tremors and decreased coordination.