Ofev (nintedanib) — Highmark
Systemic Sclerosis-associated Interstitial Lung Disease (SSc-ILD)
Initial criteria
- Documented diagnosis of SSc-ILD (ICD-10: M34.81)
- High-resolution chest CT demonstrating ≥ 10% pulmonary fibrosis
- Baseline forced vital capacity (FVC) ≥ 40%
- Percent predicted diffusing capacity of the lungs for carbon monoxide (DLCO) ≥ 30%
- Member is a non-smoker OR is currently engaged in smoking cessation
Reauthorization criteria
- Prescriber attests member has experienced disease improvement OR delayed disease progression
- Member is a non-smoker OR has maintained smoking cessation
Approval duration
12 months