PHARMACY POLICY STATEMENT Arkansas PASSE
Pharmacy benefit policy for coverage of Trikafta (elexacaftor/tezacaftor/ivacaftor tablets and ivacaftor tablets) for Arkansas PASSE members, specifying prior authorization, age, genetic mutation and dosing criteria, quantity limit, and reauthorization requirements.
New policy for Trikafta created on 2019-11-12.
Criteria updated on 2020-12-31.
Policy revised on 2021-12-22 (revised date).
Coverage Summary
Scope: Pharmacy benefit policy for coverage of Trikafta (elexacaftor/tezacaftor/ivacaftor tablets and ivacaftor tablets) for Arkansas PASSE members, specifying prior authorization, age, genetic mutation and dosing criteria, quantity limit, and reauthorization requirements. Coverage stance: covered_with_criteria. Eligible members are those covered under the pharmacy benefit (Arkansas PASSE) who meet the clinical criteria: age >= 12 years, diagnosis of cystic fibrosis and documentation of at least one CFTR mutation (including at least one F508del where indicated) or presence of an allowed CFTR mutation in chart notes, and who meet prior authorization requirements. High-level restrictions include the age threshold (>=12 years), genetic/mutation documentation requirement, prior authorization under the pharmacy benefit, and a quantity limit of an 84-count tablet carton per 28 days.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.