Kalydeco (ivacaftor) prior authorization form — coverage criteria
This document is a Cigna prior authorization form governing requests for the cystic fibrosis drug Kalydeco (ivacaftor), including new starts and continuation therapy, for Cigna members; it directs what provider information and clinical documentation are required for coverage review.
No material clinical or coverage changes in this revision.
Coverage and Authorization Criteria
Documentation-based coverage criteria
Coverage review requires submission of the completed prior authorization form with the following documented items:
Form-driven documentation requirements used to adjudicate medical necessity.
Coverage review for Kalydeco (ivacaftor) is performed based on the completed prior authorization form and submitted documentation. The form requires selection of the requested Kalydeco formulation and dosing, indication as a new start or continued therapy, the diagnosis related to use (e.g., Cystic Fibrosis or CFTR-related disorder), and supporting clinical information including CFTR gene testing and measures of clinical response for continuation requests.
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