Subject: Ofev 1882-A SGM P2024
Policy:
I. INDICATIONS
The indications below including FDA-approved indications and compendial uses are
considered a covered benefit provided that all the approval criteria are met and the member
has no exclusions to the prescribed therapy.
FDA-Approved Indications
A. Treatment of adults with idiopathic pulmonary fibrosis (IPF).
B. Treatment of adults with chronic fibrosing interstitial lung diseases (ILDs) with a progressive
phenotype.
C. Slowing the rate of decline in pulmonary function in adult patients with systemic sclerosis-
associated interstitial lung disease (SSc-ILD).
All other indications are considered experimental/investigational and not medically necessary.
II. DOCUMENTATION
Submission of the following information is necessary to initiate the prior authorization review
(where applicable):
A. Result of a chest high-resolution computed tomography (HRCT) study.
B. Pathology report of lung biopsy (if performed).
III. CRITERIA FOR INITIAL APPROVAL
A. Idiopathic Pulmonary Fibrosis (IPF)
Authorization of 12 months may be granted for treatment of idiopathic pulmonary fibrosis
when the member has undergone a diagnostic work-up which includes both of the following:
1. Other known causes of interstitial lung disease (e.g., domestic and occupational
environmental exposures, connective tissue disease, drug toxicity) have been excluded.
2. The member meets either of the following:
i. Member has completed a high-resolution computed tomography (HRCT) study of
the chest or a lung biopsy which reveals a result consistent with the usual interstitial
pneumonia (UIP) pattern.
ii. Member has completed an HRCT study of the chest which reveals a result other
than the UIP pattern (e.g., probable UIP, indeterminate for UIP) and the diagnosis is
supported by a lung biopsy. If a lung biopsy has not been previously conducted, the
diagnosis is supported by a multidisciplinary discussion between a radiologist and
pulmonologist who are experienced in IPF.
B. Chronic Fibrosing Interstitial Lung Diseases with a Progressive Phenotype
Authorization of 12 months may be granted for treatment of chronic fibrosing interstitial lung
diseases with a progressive phenotype (progressive pulmonary fibrosis [PPF]) when the
member meets both of the following:
1. The member has completed a high-resolution computed tomography (HRCT) study of
the chest that shows fibrosis affecting at least 10 percent of the lungs.
2. The member has progressive disease (e.g., forced vital capacity [FVC] decline greater
than or equal to 10% of the predicted value, worsening respiratory symptoms, increased
extent of fibrosis on HRCT).
C. Systemic Sclerosis-Associated Interstitial Lung Disease (SSc-ILD)
Authorization of 12 months may be granted for treatment of systemic sclerosis-associated
interstitial lung disease when the member’s diagnosis was confirmed by a high-resolution
computed tomography (HRCT) study of the chest.
IV. CONTINUATION OF THERAPY
All members (including new members) requesting authorization for continuation of therapy for
an indication listed in Section III may be granted an authorization of 12 months when the
member is currently receiving treatment with Ofev.
V. OTHER
Note: If the member is a current smoker, they should be counseled on the harmful effects of
smoking on pulmonary conditions and available smoking cessation options.
Place of Service:
Outpatient
The above policy is based on the following references:
- Ofev [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; October 2022.
- Raghu G, Remy-Jardin M, Richeldi L, et al. Idiopathic pulmonary fibrosis (an update) and progressive pulmonary fibrosis in adults: An official ATS/ERS/JRS/ALAT clinical practice guideline. Am J Respir Crit Care Med. 2022;205(9):e18-e47.
- Distler O, Highland KB, Gahlemann M, et al. Nintedanib for systemic sclerosis-associated interstitial lung disease. N Engl J Med. 2019;380(26):2518-2528.
- van den Hoogen F, Khanna D, Fransen J, et al. 2013 Classification criteria for systemic sclerosis: an American College of Rheumatology/European League against Rheumatism collaborative initiative. Arthritis Rheum. 2013;65(11):2737-47.
- Flaherty KR, Wells AU, Cottin V, et al. Nintedanib in progressive fibrosing interstitial lung diseases. N Engl J Med. 2019;381(18):1718-1727.
- Rahaghi FF, Hsu VM, Kaner RJ, et al. Expert consensus on the management of systemic sclerosis-associated interstitial lung disease. Respir Res. 2023;24(1):6-16.
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 09, 2024
