Subject: Daliresp PA Policy 646-A UDR 10-2023
Policy:
FDA-APPROVED INDICATIONS
Daliresp is indicated as a treatment to reduce the risk of COPD exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations.
Limitations of Use
Daliresp is not a bronchodilator and is not indicated for the relief of acute bronchospasm.
Daliresp 250 mcg is a starting dose, for the first 4 weeks of treatment only and is not the effective (therapeutic) dose.
COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
• The requested drug is being prescribed to reduce the risk of chronic obstructive
pulmonary disease (COPD) exacerbations in a patient with severe COPD associated
with chronic bronchitis and a history of exacerbations
Duration of Approval (DOA):z
• 646-A: DOA: 12 months
Place of Service:
Outpatient
The above policy is based on the following references:
- Daliresp [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; March 2019.
- Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Waltham, MA: UpToDate, Inc.; 2023. https://online.lexi.com. Accessed August 8, 2023.
- Micromedex (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 08/08/2023).
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.
April 14, 2024
