Esbriet tablets (267 mg and 801 mg) — Medica

Preferred products

• generic pirfenidone tablets (267 mg and 801 mg)
• generic pirfenidone capsules (267 mg)

Initial criteria

• Patient meets the standard Idiopathic Pulmonary Fibrosis and Related Lung Disease – Pirfenidone Prior Authorization Policy criteria; AND
• Patient has tried generic pirfenidone [documentation required]; AND
• Patient cannot take generic pirfenidone due to a formulation difference in the inactive ingredient(s) (e.g., difference in dyes, fillers, preservatives) between the brand and bioequivalent generic product which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]

Approval duration

1 year