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Esbriet — Blue Cross Blue Shield of Alabama

idiopathic pulmonary fibrosis (IPF)

Initial criteria

  • Patient has a diagnosis of idiopathic pulmonary fibrosis (IPF)
  • Other known causes of interstitial lung disease (ILD) have been excluded (e.g., domestic and occupational environmental exposures, connective tissue diseases, drug toxicities, alternative diagnoses, etc)
  • ONE of the following: patient had a high-resolution computed tomography (HRCT) scan showing a pattern for usual interstitial pneumonia (UIP); OR surgical lung biopsy confirming UIP; OR HRCT showing probable UIP and surgical lung biopsy indicating probable UIP; OR patient has another FDA labeled indication for the requested agent and route of administration
  • If request is for brand Esbriet with available generic equivalent pirfenidone, ONE of the following: intolerance or hypersensitivity to generic equivalent not expected with brand; OR FDA labeled contraindication to generic equivalent not expected with brand; OR support for use of brand agent over the generic equivalent
  • Prescriber is a specialist in the area of the diagnosis (e.g., pathologist, pulmonologist, radiologist, rheumatologist) or has consulted with a specialist
  • Patient will NOT use the requested agent in combination with another agent included in this prior authorization program
  • Patient does NOT have any FDA labeled contraindications to requested agent

Reauthorization criteria

  • Patient previously approved for the requested agent through the plan’s Prior Authorization process
  • Patient has had clinical benefit with the requested agent
  • If request is for brand Esbriet with available generic equivalent pirfenidone, ONE of the following: intolerance or hypersensitivity to generic equivalent not expected with brand; OR FDA labeled contraindication to generic equivalent not expected with brand; OR support for use of brand agent over generic
  • Prescriber is a specialist in the area of the diagnosis (e.g., pathologist, pulmonologist, radiologist, rheumatologist) or has consulted with a specialist
  • Patient will NOT use the requested agent in combination with another agent included in this prior authorization program
  • Patient does NOT have any FDA labeled contraindications to requested agent

Approval duration

12 months