CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Daliresp (roflumilast) prior authorization for COPD

Defines prior authorization coverage criteria for Daliresp (roflumilast) to reduce risk of COPD exacerbations in patients with severe COPD associated with chronic bronchitis and history of exacerbations. Includes FDA-approved indication notes and limitation that 250 mcg is a starter dose only.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDaliresp (roflumilast) prior authorization for COPD

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required; document severe COPD with chronic bronchitis and history of exacerbations to support approval.

POLICY UPDATE CHANGES

No material changes

1Covered Indication (COPD with chronic bronchitis and prior exacerbations)

1Starter dose note (250 mcg for first 4 weeks only)

Initial Prior Authorization Criteria

Initial Prior Authorization Criteria for Daliresp (roflumilast)

The requested drug will be covered with prior authorization when the following criteria are met:

FDA-Approved Indication and Limitations

Daliresp indicated to reduce risk of COPD exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations
Daliresp is not a bronchodilator and is not indicated for relief of acute bronchospasm
Daliresp 250 mcg is a starting dose for the first 4 weeks only and is not the effective (therapeutic) dose

Provider Actions

Prior Authorization

Prior authorization required

Prior authorization is required and coverage is granted only when criteria are met that the drug is prescribed to reduce COPD exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations.

Indication: reduce risk of COPD exacerbations in severe COPD with chronic bronchitis
Requirement: history of exacerbations

Documentation Required

Document indication and exacerbation history

Document that the patient has severe COPD associated with chronic bronchitis and a prior history of exacerbations to support prior authorization for Daliresp.

Diagnosis: severe COPD with chronic bronchitis
Dates and descriptions of prior exacerbations (episodes, hospitalizations, ED visits)