supporting skeletal muscle related symptoms that resolved when statin therapy was discontinued; and documentation the member has been rechallenged at a lower dose or with a different statin. Idiopathic Pulmonary Non-formulary use of Esbriet or Ofev can be approved when the following are met: Initial Approval: 3 months Fibrosis Agents Diagnosis of mild to moderate idiopathic pulmonary fibrosis Last reviewed: 06/16/15 Confirmed by high resolution computed tomography (HRCT), lung biopsy, or Renewal: 6 months bronchoscopy Esbriet Criteria for renewal: Interstitial lung disease cannot be attributed to another cause (i.e., rheumatoid Ofev Documentation of arthritis, lupus, systemic sclerosis, asbestos exposure, or hypersensitivity stable FVC pneumonitis) (recommended to Forced vital capacity (FVC) between 50 and 80% predicted discontinue if there is a Documentation of baseline liver function tests (LFT’s) prior to initiating treatment >10% decline in FVC Patient age must be 18 years or greater over a 12 month Patient is not a current smoker period) Prescribed by, or in consultation with, a pulmonologist Attestation that LFT’s are being monitored Note: There is no conclusive evidence to support the use of any drugs to increase the survival of people with idiopathic pulmonary fibrosis. Increlex For patients that meet the following: Initial Approval: Prescribed by or in consultation with pediatric endocrinologist Last reviewed: 4/22/15 6 months Patient is 2 years old ≥ No evidence of epiphyseal closure Renewal: No evidence of neoplastic disease 6 months if at least Documentation supports a diagnosis of Severe, Primary IGF-1 deficiency doubling of Height standard deviation score less than or equal to pretreatment −3 Basal IGF-1 standard deviation score less than or equal to growth velocity −3 Normal or elevated growth hormone (GH) levels 1 year if growth No evidence of secondary forms of IGF-1 deficiency, such as GH deficiency, velocity 2.5 cm/yr ≥ malnutrition, hypothyroidism, or chronic treatment with pharmacologic doses of and epiphyses are corticosteroids. open OR
supporting skeletal muscle related symptoms that resolved when statin therapy was discontinued; and documentation the member has been rechallenged at a lower dose or with a different statin. Idiopathic Pulmonary Fibrosis Agents Last reviewed: 06/16/15 Esbriet Ofev Non-formulary use of Esbriet or Ofev can be approved when the following are met: Diagnosis of mild to moderate idiopathic pulmonary fibrosis Confirmed by high resolution computed tomography (HRCT), lung biopsy, or bronchoscopy Interstitial lung disease cannot be attributed to another cause (i.e., rheumatoid arthritis, lupus, systemic sclerosis, asbestos exposure, or hypersensitivity pneumonitis) Forced vital capacity (FVC) between 50 and 80% predicted Documentation of baseline liver function tests (LFT’s) prior to initiating treatment Patient age must be 18 years or greater Patient is not a current smoker Prescribed by, or in consultation with, a pulmonologist Note: There is no conclusive evidence to support the use of any drugs to increase the survival of people with idiopathic pulmonary fibrosis. Initial Approval: 3 months Renewal: 6 months Criteria for renewal: Documentation of stable FVC (recommended to discontinue if there is a >10% decline in FVC over a 12 month period) Attestation that LFT’s are being monitored Increlex Last reviewed: 4/22/15 For patients that meet the following: Prescribed by or in consultation with pediatric endocrinologist Patient is ≥ 2 years old No evidence of epiphyseal closure No evidence of neoplastic disease Documentation supports a diagnosis of Severe, Primary IGF-1 deficiency Height standard deviation score less than or equal to −3 Basal IGF-1 standard deviation score less than or equal to −3 Normal or elevated growth hormone (GH) levels No evidence of secondary forms of IGF-1 deficiency, such as GH deficiency, malnutrition, hypothyroidism, or chronic treatment with pharmacologic doses of corticosteroids. OR Initial Approval: 6 months Renewal: 6 months if at least doubling of pretreatment growth velocity 1 year if growth velocity ≥ 2.5 cm/yr and epiphyses are open
MMIC-PA-SMI-Guidelines.docx