Ofev — CareFirst (Caremark)

Initial criteria

• Member has undergone a diagnostic work-up which includes exclusion of other known causes of interstitial lung disease (e.g., domestic and occupational environmental exposures, connective tissue disease, drug toxicity).
• Member has completed a high-resolution computed tomography (HRCT) study of the chest or a lung biopsy revealing a result consistent with the usual interstitial pneumonia (UIP) pattern OR member has completed an HRCT of the chest showing a result other than the UIP pattern (e.g., probable UIP, indeterminate for UIP) and diagnosis is supported by a lung biopsy, or if no biopsy has been performed, the diagnosis is supported by a multidisciplinary discussion between a radiologist and pulmonologist experienced in IPF.

Reauthorization criteria

• Member is currently receiving treatment with Ofev.

Approval duration

12 months