Esbriet — CareFirst (Caremark)

Initial criteria

• Member has undergone a diagnostic work-up which includes both of the following: (A) Other known causes of interstitial lung disease (e.g., domestic and occupational environmental exposures, connective tissue disease, drug toxicity) have been excluded; AND (B) The member meets either of the following: (1) Member has completed a high-resolution computed tomography (HRCT) study of the chest or a lung biopsy which reveals a result consistent with the usual interstitial pneumonia (UIP) pattern; OR (2) Member has completed an HRCT study of the chest which reveals a result other than the UIP pattern (e.g., probable UIP, indeterminate for UIP, alternative diagnosis) and the diagnosis is supported by a lung biopsy, or if a lung biopsy has not been previously conducted, the diagnosis is supported by a multidisciplinary discussion between a radiologist and pulmonologist who are experienced in IPF.

Reauthorization criteria

• Member is currently receiving treatment with the requested medication for idiopathic pulmonary fibrosis.

Approval duration

12 months