Daliresp® (roflumilast tablets) — Cigna
chronic obstructive pulmonary disease (COPD)
Preferred products
- Yupelri® (revefenacin inhalation solution)
- Alvesco® (ciclesonide inhalation aerosol)
- ArmonAir® Digihaler® (fluticasone propionate inhalation powder)
- Arnuity® Ellipta® (fluticasone furoate inhalation powder)
- Asmanex® HFA (mometasone inhalation aerosol)
- Asmanex® Twisthaler® (mometasone inhalation powder)
- Flovent Diskus® (fluticasone propionate inhalation powder, generic)
- Flovent HFA (fluticasone propionate inhalation aerosol, generic)
- Pulmicort Flexhaler® (budesonide inhalation powder)
- Qvar® RediHaler® (beclomethasone HFA inhalation aerosol)
- Pulmicort Respules® (budesonide inhalation suspension, generic)
- Advair Diskus® (fluticasone propionate/salmeterol inhalation powder, generic [including Wixela Inhub®])
- Breo® Ellipta® (fluticasone furoate/vilanterol inhalation powder, generic)
- Symbicort® (budesonide/formoterol fumarate inhalation aerosol, generic [including Breyna®])
- Anoro® Ellipta® (umeclidinium and vilanterol inhalation powder)
- Bevespi Aerosphere® (glycopyrrolate and formoterol fumarate inhalation aerosol)
- Duaklir® Pressair® (aclidinium bromide and formoterol fumarate inhalation powder)
- Stiolto® Respimat® (tiotropium bromide and olodaterol inhalation spray)
- Utibron® Neohaler® (indacaterol and glycopyrrolate inhalation powder)
- Breztri Aerosphere® (budesonide, glycopyrrolate, and formoterol fumarate inhalation aerosol)
- Trelegy® Ellipta® (fluticasone furoate, umeclidinium, and vilanterol inhalation powder)
Initial criteria
- Individual is age ≥ 18 years
- Individual has a diagnosis of chronic obstructive pulmonary disease (COPD)
- Documentation is provided that the individual has tried or is currently using at least one preferred product from the Step Therapy list (e.g., LAMA, LABA, ICS, or combination thereof) OR there is a contraindication or intolerance to all preferred products
Reauthorization criteria
- Individual continues to meet the initial criteria
- Individual has demonstrated therapeutic benefit from roflumilast therapy (e.g., reduction in COPD exacerbations)
Approval duration
12 months