Subject: pirfenidone-Esbriet 1881-A SGM P2024

Drug

ESBRIET  (pirfenidone )

pirfenidone

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 Indication
          Esbriet/pirfenidone is indicated for the treatment of idiopathic pulmonary fibrosis (IPF).

           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:
          A.  Result of a chest high-resolution computed tomography (HRCT) study.
          B.  Pathology report of lung biopsy (if performed).


   III.  CRITERIA FOR INITIAL APPROVAL

          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:
          A.  Other known causes of interstitial lung disease (e.g., domestic and occupational
               environmental exposures, connective tissue disease, drug toxicity) have been excluded.
          B.  The member meets either of the following:
               1.  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.
               2.  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, alternative diagnosis) 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.


   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 the requested medication.

    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:

1. Esbriet [package insert]. South San Francisco, CA: Genentech USA, Inc.; March 2023.
2. Pirfenidone [package insert]. Berkeley Heights, NJ: Laurus Labs Limited; March 2023.
3. 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.

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