COPD Agents Prior Authorization (PDE inhibitors and other COPD agents)
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Prior authorization form and requirements for COPD pharmacologic agents (including PDE inhibitors such as roflumilast and ensifentrine) for Geisinger Health Plan members; applies to prescribers requesting new or renewal coverage. Providers must complete the form and submit required clinical documentation.
No material clinical or coverage changes in this revision.
Coverage Criteria for COPD Agents
Initial Therapy
Covered when ALL of the following are met (initial requests):
Prescriber must document findings on the prior authorization form; liver impairment is a contraindication for roflumilast.
Document trials, failures, or contraindications on the form; refer to preferred drug list for other COPD agents.
Applies to all PDE inhibitors due to psychiatric risk warnings; document evaluation and prescriber's determination of candidacy.
Continuation/Renewal Therapy
Covered on renewal when ALL of the following are met:
Requires documentation of change in exacerbation frequency and current liver status in recent chart notes.
Positive response and mental health assessment must be documented in chart notes.
Follow form instructions for renewal requests and include supporting documentation when submitting to PromptPA or fax.
Roflumilast (Daliresp) is contraindicated in beneficiaries with moderate or severe liver impairment (Child-Pugh B or C). This contraindication must be documented in the chart for both initial and renewal requests; lack of documentation may result in denial.
Requests for phosphodiesterase (PDE) inhibitors without required clinical documentation are not acceptable. Providers must document COPD severity per current GOLD criteria, required disease-specific findings (for example, chronic bronchitis criteria or an mMRC score ≥2 where applicable), prior trials and failures or documented contraindications/intolerances to first-line therapies (LABA, LAMA, and inhaled corticosteroid when indicated), and mental health evaluation or specialist treatment when indicated (history of serious mental health or substance use disorders). Renewal requests must also include objective evidence of benefit (e.g., decreased exacerbation frequency for roflumilast or improved pulmonary function/symptoms for ensifentrine).
Provider Requirements and Submission Instructions
Prior authorization required
Prior authorization is required for COPD agents. Providers must submit the completed COPD Agents Prior Authorization Form and required clinical documentation for both new and renewal requests via PromptPA or fax.
- Submit new and renewal requests using the COPD Agents Prior Authorization Form.
- Acceptable submission routes: PromptPA (https://ghp.promptpa.com) or fax to 570-271-5610.
Step / therapeutic trial requirements
Document a trial and failure, or a documented contraindication or intolerance, to preferred first-line therapies before requesting PDE inhibitors or other non-preferred COPD agents.
- For PDE inhibitors and other non-preferred COPD agents, document trials of LABA and LAMA and inhaled corticosteroid (unless eosinophils <100 cells/µL with lab documentation).
- Refer to the preferred drug list for preferred vs non-preferred COPD agents (papdl.com).
Required submission materials
Include a completed prior authorization form with beneficiary and prescriber information, drug requested (strength, directions, quantity, duration), diagnosis with ICD-10 code, and recent chart notes demonstrating required clinical criteria.
- Ensure drug fields (strength, directions, quantity, duration) are completed.
- Include diagnosis and required ICD-10 code and supporting clinical documentation (e.g., lung function, mMRC score, exacerbation history).
- Submit completed form and supporting documentation via PromptPA or fax to 570-271-5610.
Documentation deficiencies may cause denial or return
Requests missing required clinical documentation may be denied or returned. Missing documentation can include lack of disease severity evidence, absence of prior trials/failures or contraindication documentation, missing mental health evaluation when indicated, or no evidence of benefit on renewal.
- Failure to document contraindication status (e.g., liver impairment for roflumilast) can lead to denial.
- Renewal requests must document clinical benefit (e.g., decreased exacerbations for roflumilast or objective improvement with ensifentrine).
Background and Scope
This prior authorization form covers the pharmacologic management of COPD, including phosphodiesterase (PDE) inhibitors such as roflumilast (Daliresp) and ensifentrine (Ohtuvayre). It requires documentation of disease severity per current GOLD guidelines, agent-specific criteria (for example, chronic bronchitis and absence of moderate-to-severe liver impairment for roflumilast; mMRC score ≥2 for ensifentrine), exclusion of other causes of chronic airflow limitation, and evidence of trials/failures or contraindications to first-line inhaled therapies. The form applies to both new and renewal requests and must be submitted with supporting clinical records via PromptPA or fax.
Key Definitions and Thresholds
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