Ofev (nintedanib) — United Healthcare

Idiopathic pulmonary fibrosis (IPF)

Initial criteria

Diagnosis of idiopathic pulmonary fibrosis (IPF) as documented by all of the following:
Exclusion of other known causes of interstitial lung disease (e.g., domestic and occupational environmental exposures, connective tissue disease, drug toxicity)
ICD-10 Code J84.112 (Idiopathic pulmonary fibrosis)
One of the following:
In patients not subjected to surgical lung biopsy: presence of a usual interstitial pneumonia (UIP) pattern on HRCT revealing IPF or probable IPF
In patients subjected to a lung biopsy: both HRCT and surgical lung biopsy pattern reveal IPF or probable IPF
If request is for Esbriet, Esbriet is not used in combination with Ofev
If request is for Ofev, Ofev is not used in combination with Esbriet
Prescriber is a pulmonologist

Documentation of positive clinical response to Esbriet or Ofev therapy, as applicable
If Esbriet: not used in combination with Ofev
If Ofev: not used in combination with Esbriet

12 months