Antifibrotic Respiratory Agents Prior Authorization
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Form and prior authorization requirements for antifibrotic respiratory medications for Geisinger Health Plan members; applies to prescribers requesting initial or renewal coverage. It guides documentation, trial/failure of preferred agents, specialist involvement, and renewal assessments.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy
Initial requests for non-preferred antifibrotic agents
Refer to payer preferred drug list for preferred agents (https://papdl.com/preferred-drug-list).
Continuation Therapy / Renewal
Renewal requests
Submit documentation; send via PromptPA or fax as instructed.
Provider Qualifications
Specialist involvement
Form includes checkbox and asks for submission of consultation documentation.
Initial request requirements
Initial request requirements
Refer to preferred drug list link on form and submit supporting documentation.
Diagnosis and Coding
| DX code (required) | Diagnosis code for the indication |
Provider Actions and Submission Instructions
Prior authorization required — submit Antifibrotic Respiratory Agents form
Prior authorization is required for antifibrotic respiratory agents. Complete and submit the Antifibrotic Respiratory Agents Prior Authorization Form with supporting documentation for new and renewal requests.
- Complete the Antifibrotic Respiratory Agents Prior Authorization Form
- Include supporting clinical documentation for initial and renewal requests
Documentation required for non-preferred agents: trial/failure or contraindication/intolerance
For requests of non-preferred antifibrotic agents, provide documentation of a history of trial and failure of preferred antifibrotic agents appropriate to the beneficiary’s diagnosis, or documentation of a contraindication or intolerance to preferred agents.
- Refer to the payer’s preferred drug list for preferred agents (link provided on form)
- Attach documentation demonstrating trial/failure or documented contraindication/intolerance
Submit completed form with diagnosis, DX code, and specialist/medication documentation
Submit the completed prior authorization form with the beneficiary diagnosis and DX code, and include documentation of specialist involvement or consultation when applicable. If the member is already on the requested medication, include current treatment status and documentation; for dose adjustments, include rationale (e.g., liver impairment, interactions, adverse effects).
- Include Diagnosis and DX code (required) on the form
- Document if prescribed by or in consultation with a pulmonologist, rheumatologist, or other specialist; attach consultation notes if applicable
- If beneficiary is currently treated with the requested medication, submit supporting documentation
- Provide documentation for any dose adjustments and rationale
Submission channels — PromptPA or fax
Send the completed Antifibrotic Respiratory Agents Prior Authorization Form and all required clinical documentation via PromptPA (https://ghp.promptpa.com) or fax to Geisinger Health Plan at 570-271-5610.
- Electronic submission: PromptPA https://ghp.promptpa.com
- Fax submission: 570-271-5610
Denial risk for non-preferred agents lacking trial/failure or contraindication documentation
Requests for non-preferred antifibrotic agents may be denied if there is no documented history of trial and failure of preferred antifibrotic agents or no documented contraindication/intolerance to preferred agents.
- Ensure trial/failure or contraindication/intolerance documentation is attached for non-preferred agent requests
Denial risk for incomplete or missing clinical documentation on initial or renewal requests
Failure to provide the required clinical documentation for initial or renewal requests may result in denial. Required documentation includes diagnosis and DX code, consultation documentation (if applicable), current treatment status (if already on medication), dose-adjustment rationale, evidence of trial/failure or contraindication/intolerance for non-preferred agents, smoking status/counseling (initial), and for renewals evidence of positive clinical response and adverse reaction documentation per FDA labeling.
- Include all items requested on the form; incomplete submissions risk denial
- For renewals, include documentation of positive clinical response and any adverse reactions requiring dose modification
Definitions and Request Details
Step Therapy and Trials
| Requirement | Documentation required |
|---|---|
| For a non-preferred antifibrotic respiratory agent, beneficiary must have history of trial and failure of, or a contraindication or intolerance to, preferred antifibrotic respiratory agents appropriate for the beneficiary's diagnosis or indication. | |
| Submit documentation showing trial and failure of preferred agents or documentation of contraindication/intolerance; refer to payer preferred drug list for preferred agents (https://papdl.com/preferred-drug-list). |
Initial Therapy Specifics
Initial request requirements
Initial request requirements
Refer to preferred drug list link on form and submit supporting documentation.
Continuation / Renewal Specifics
Renewal requirements
Renewal requests
Submit completed form and required clinical documentation via PromptPA or fax to Geisinger Health Plan.
Background
This prior authorization form supports clinical review of antifibrotic respiratory agents, which are used to treat fibrotic interstitial lung diseases and other antifibrotic‑indicated respiratory conditions. The form collects the diagnosis and DX code, medication details (drug, strength, formulation, dose, quantity, refills), specialist involvement or consultation, current treatment status, dose adjustments relevant to liver impairment or interactions, smoking status and counseling, and documentation of clinical response or adverse effects to inform approval decisions. The information requested on the form and the payer's preferred drug list are used to determine medical necessity and appropriate coverage.
Providers must complete and submit the Antifibrotic Respiratory Agents Prior Authorization Form for both new (initial) and renewal requests. For initial requests of a non‑preferred agent, the form requires documentation that the beneficiary has a history of trial and failure of, or a contraindication/intolerance to, preferred antifibrotic agents appropriate for the diagnosis (refer to the payer's preferred drug list). For renewals, the form requires documentation of a positive clinical response to the requested medication and documentation of any adverse reactions and dose adjustments per FDA‑approved labeling (e.g., liver enzyme elevations, GI effects, photosensitivity, rash).
The form asks whether the medication is prescribed by or in consultation with a pulmonologist, rheumatologist, or other specialist and requires submission of consultation documentation when applicable. It also queries smoking status and whether cessation was advised, and it requests documentation of any current treatment with the requested medication and rationale for dose modifications.
Submit the completed form and required clinical documentation via PromptPA (https://ghp.promptpa.com) or fax to Geisinger Health Plan at 570‑271‑5610. Incomplete submissions — for example, lacking documentation of trial/failure or contraindication for non‑preferred agents, diagnosis/DX code, specialist consultation, or renewal evidence of response and safety monitoring — may result in denial.
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