Subject: Specialty Quantity Limit Esbriet 3205-H P2022
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for
the most common uses of the medication. The recommended
dosing parameters for the treatment of idiopathic pulmonary
fibrosis fall within the standard limits. Coverage of an
additional quantity may be reviewed on a case-by-case basis
upon request.
II. COVERED QUANTITIES
|
Medication
|
Standard Limit
|
FDA-recommended dosing
|
|
Esbriet
(pirfenidone)
capsules 267 mg
in 14-day titration
blister pack
|
63 capsules
per 14 days
|
Idiopathic pulmonary fibrosis:
Days 1 through 7: 267 mg (one 267 mg capsule/tablet)
three times daily (801 mg/day)
Days 8 through 14: 534 mg (two 267 mg capsules/tablets)
three times daily (1602 mg/day)
Days 15 onward: 801 mg (three 267 mg capsules/tablets or
one 801 mg tablet) three times daily (2403 mg/day)
|
|
Esbriet
(pirfenidone)
capsules 267 mg
in 4-week
maintenance blister
pack
|
252 capsules
per 28 days
|
|
Esbriet
(pirfenidone)
capsules 267 mg
|
270 per 30 days
|
|
Esbriet
(pirfenidone)
tablets 267 mg
|
270 per 30 days
|
|
Esbriet
(pirfenidone)
tablets 801 mg
|
90 per 30 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Esbriet [package insert]. South San Francisco, CA: Genentech USA, Inc.; July 2019.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
June 26, 2022
