Esbriet (pirfenidone capsules and film-coated tablets - Genentech, generic) — Cigna

Initial criteria

• Patient is age ≥ 18 years
• Forced vital capacity is ≥ 40% of predicted value
• Diagnosis of idiopathic pulmonary fibrosis is confirmed by ONE of the following: (a) findings on high-resolution computed tomography indicate usual interstitial pneumonia; OR (b) a surgical lung biopsy demonstrates usual interstitial pneumonia
• Medication is prescribed by or in consultation with a pulmonologist

Reauthorization criteria

• Patient is age ≥ 18 years
• Patient has experienced a beneficial response to therapy over the last year while receiving pirfenidone (for a patient who has received less than 1 year of therapy, response is from baseline prior to initiating pirfenidone)
• Examples of a beneficial response include a reduction in the anticipated decline in forced vital capacity, six-minute walk distance, and/or a reduction in the number or severity of idiopathic pulmonary fibrosis exacerbations
• Medication is prescribed by or in consultation with a pulmonologist

Approval duration

1 year