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Esbriet — Blue Cross Blue Shield of New Mexico

Idiopathic pulmonary fibrosis (IPF)

Initial criteria

  • Diagnosis of idiopathic pulmonary fibrosis (IPF) AND ALL of the following:
  • • 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)
  • • ONE of the following HRCT or biopsy findings:
  • – High-resolution computed tomography (HRCT) scan showing a pattern for usual interstitial pneumonia (UIP) OR
  • – Surgical lung biopsy with pathology confirming UIP OR
  • – HRCT scan showing probable UIP AND surgical lung biopsy indicating probable UIP
  • OR
  • The patient has another FDA labeled indication for the requested agent and route of administration
  • AND if the request is for a brand agent with an available generic equivalent:
  • • ONE of the following:
  • – Patient currently treated and stable on requested brand (chart notes required) OR
  • – Tried and had inadequate response with generic equivalent OR
  • – Intolerance or hypersensitivity to generic equivalent that is NOT expected to occur with brand OR
  • – FDA labeled contraindication to generic equivalent that is NOT expected to occur with brand OR
  • – Generic discontinued due to lack of efficacy, diminished effect, or adverse event OR
  • – Generic expected to be ineffective or create adherence barrier or worsen comorbid condition OR
  • – Generic NOT in best interest of the patient based on medical necessity OR
  • – Tried another drug in same class discontinued due to ineffectiveness, diminished effect, or adverse event AND support exists for brand use over generic
  • • Brand–generic pair: Esbriet – pirfenidone
  • Prescriber is a specialist in the area of the diagnosis (e.g., pulmonologist, rheumatologist, radiologist, pathologist) OR consulted with specialist
  • Patient will NOT use the requested agent in combination with another agent in this PA program
  • No FDA labeled contraindications to the requested agent

Reauthorization criteria

  • Prior approval for the requested agent through plan’s PA process
  • Documented clinical benefit with the requested agent
  • If brand with generic equivalent, same brand vs. generic criteria as initial apply
  • Prescriber is a specialist in the diagnosis area or has consulted one
  • Not used in combination with another agent in the PA program
  • No FDA labeled contraindications to requested agent

Approval duration

12 months