Pirfenidone — Medical Mutual

Idiopathic Pulmonary Fibrosis (IPF)

Initial criteria

Patient is age ≥ 18 years; AND
Forced vital capacity is ≥ 40% of the predicted value; AND
Diagnosis of idiopathic pulmonary fibrosis is confirmed by one of the following: Findings on high-resolution computed tomography indicates usual interstitial pneumonia OR A surgical lung biopsy demonstrates usual interstitial pneumonia; AND
Medication is prescribed by, or in consultation with, a pulmonologist

Patient is age ≥ 18 years; AND
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 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); AND
Medication is prescribed by, or in consultation with, a pulmonologist

1 year