Ofev (nintedanib) — Highmark

Chronic Fibrosing Interstitial Lung Disease (ILD) with Progressive Phenotype

Initial criteria

Documented diagnosis of chronic fibrosing ILD with progressive phenotype (ICD-10: J84.170)
High-resolution chest CT demonstrating > 10% pulmonary fibrosis
Evidence of disease progression within the previous 24 months despite treatment meeting one of: relative decline in FVC ≥ 10% predicted, OR relative decline in FVC 5–<10% predicted with worsening respiratory symptoms, OR relative decline in FVC 5–<10% predicted with increasing fibrotic changes on HRCT, OR worsening respiratory symptoms and increasing fibrotic changes on HRCT
Baseline forced vital capacity (FVC) ≥ 45%
Percent predicted diffusing capacity of the lungs for carbon monoxide (DLCO) ≥ 30%
Member is a non-smoker OR is currently engaged in smoking cessation

Prescriber attests member has experienced disease improvement OR delayed disease progression
Member is a non-smoker OR has maintained smoking cessation

12 months