CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A
Kalydeco (ivacaftor) for cystic fibrosis
Policy governs prior authorization, coverage criteria, required documentation, prescriber specialty, and continuation criteria for ivacaftor (Kalydeco) for treatment of cystic fibrosis in members age ≥1 month with specified CFTR mutations. All other indications are considered investigational/not medically necessary.
Policy Summary
PayerNeighborhood Health Plan of Rhode Island
PolicyKalydeco (ivacaftor) for cystic fibrosis
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionSubmit genetic testing report confirming the appropriate CFTR mutation for initial prior authorization; authorization may be granted for 12 months when criteria are met.
POLICY UPDATE CHANGES
No material clinical or coverage changes.
1Minimum age (months)
~80+Listed responsive CFTR mutations
12 monthsAuthorization duration
Coverage Summary
Coverage stance: covered_with_criteria. Scope: Policy governs prior authorization, coverage criteria, required documentation, prescriber specialty, and continuation criteria for ivacaftor (Kalydeco) for treatment of cystic fibrosis in members age ≥1 month with specified CFTR mutations.