Note: Emapalumab (Gamifant) is not indicated for the treatment of secondary HLH.
Note: Prior to emapalumab (Gamifant) administration, individual should be evaluated for infection, including latent tuberculosis (TB). Prophylaxis for TB should be administered to individuals who are at risk for TB or known to have positive purified protein derivative (PPD) test result or positive interferon gamma release assay. Individuals should also be administered prophylaxis for herpes zoster, Pneumocystis jirovecii, and fungal infections prior to emapalumab (Gamifant) administration. During treatment, individuals should be monitored for TB, adenovirus, Epstein-Barr virus (EBV), and cytomegalovirus (CMV) every two weeks and as clinically indicated.
NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.