COVERED USES:

FDA Approved Indications:

1. Reducing the frequency and severity of serious infections associated with Chronic Granulomatous Disease (CGD)
2. Delaying time to disease progression in patients with severe, malignant osteopetrosis.

All FDA-approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

The condition being treated meets the "Covered Uses" criteria above.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization will be approved for up to 6 months. Reauthorization will be approved for up to one year.