Ofev (nintedanib) — Highmark

Preferred products

• generic pirfenidone tablets

Initial criteria

• Documented diagnosis of idiopathic pulmonary fibrosis (IPF) (ICD-10: J84.112)
• Baseline forced vital capacity (FVC) ≥ 50%
• Baseline percent predicted diffusing capacity of the lungs for carbon monoxide (DLCO) ≥ 30%
• Member is a non-smoker OR is currently engaged in smoking cessation
• If request is for brand Esbriet tablets, member experienced therapeutic failure or intolerance to generic pirfenidone tablets
• If request is for brand Esbriet capsules, member experienced therapeutic failure or intolerance to plan-preferred, generic pirfenidone tablets

Reauthorization criteria

• Prescriber attests member has experienced disease improvement OR delayed disease progression
• Member is a non-smoker OR has maintained smoking cessation
• If request is for brand Esbriet tablets, member experienced therapeutic failure or intolerance to generic pirfenidone tablets
• If request is for brand Esbriet capsules, member experienced therapeutic failure or intolerance to plan-preferred, generic pirfenidone tablets

Approval duration

12 months