pirfenidone (Esbriet®)


Indications for Prior Authorization:

  • Treatment of idiopathic pulmonary fibrosis (IPF)

Patients must meet the following criteria for the indication(s) above:

  • Diagnosis if IPF by pulmonologist

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

  • All non-FDA approved uses not listed in the approved indications


  • Dose should be titrated over 14 days
  • Dose is 801 mg (three 267 mg capsules) three times a day
  • Doses should be administered at the same times each day
  • Higher doses are not approvable
  • Dose modification is required for adverse events and elevated liver function tests


One year


Last review date: December 1, 2014

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