Target Agent(s) — Blue Cross Blue Shield of Kansas

Initial criteria

• ONE of the following must be met:
• A. Diagnosis of idiopathic pulmonary fibrosis (IPF) AND ALL of the following:
• 1. Other known causes of interstitial lung disease have been excluded (e.g., environmental exposures, connective tissue diseases, drug toxicities, alternative diagnoses) AND
• 2. ONE of the following:
• A. High-resolution computed tomography (HRCT) showing usual interstitial pneumonia (UIP) pattern OR
• B. Surgical lung biopsy confirming UIP OR
• C. HRCT showing probable UIP pattern AND surgical lung biopsy indicating probable UIP;
• B. Diagnosis of systemic sclerosis–associated interstitial lung disease (SSc‑ILD) AND ALL of the following:
• 1. Diagnosis confirmed by HRCT or chest radiography, AND
• 2. ONE of the following:
• A. Tried and had inadequate response to ONE conventional agent (e.g., mycophenolate mofetil, cyclophosphamide, azathioprine) OR
• B. Intolerance or hypersensitivity to ONE conventional agent OR
• C. FDA labeled contraindication to ALL conventional agents;
• C. Diagnosis of chronic fibrosing interstitial lung disease (ILD) with a progressive phenotype AND BOTH of the following:
• 1. Meets TWO of these criteria within the past year: worsening respiratory symptoms OR physiologic evidence of disease progression OR radiologic evidence of disease progression AND
• 2. Alternative explanations of worsening features have been excluded;
• D. Has another FDA‑labeled indication for the requested agent and route of administration;
• AND if patient has an FDA‑labeled indication, ONE of the following must also apply:
• A. Patient’s age is within FDA labeling for the requested indication, OR
• B. There is support for using the agent for patient’s age for the requested indication;
• AND
• The prescriber is a specialist (pathologist, pulmonologist, radiologist, or rheumatologist) or has consulted with one;
• AND
• The requested agent will NOT be used in combination with another agent included in this prior authorization program;
• AND
• The patient does NOT have any FDA‑labeled contraindications to the requested agent.

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process;
• AND patient has had clinical benefit with the requested agent;
• AND prescriber is a specialist in area of diagnosis or has consulted one;
• AND agent will not be used in combination with another agent included in this prior authorization program;
• AND patient does not have any FDA labeled contraindications to the requested agent.

Approval duration

12 months