Target Agent(s) — Blue Cross Blue Shield of Kansas

diagnosis other than cystic fibrosis

Reauthorization criteria

Patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
ONE of the following: (A) Patient has a diagnosis of cystic fibrosis AND has had improvements or stabilization with the requested agent (e.g., improvement or stabilization of FEV1, weight/BMI, CFQR Respiratory Domain score, respiratory symptoms related to CF, number of pulmonary exacerbations) OR (B) Patient has a diagnosis other than cystic fibrosis AND has had clinical benefit with the requested agent AND
Patient will NOT be using the requested agent in combination with another CFTR modulator agent for the requested indication AND
Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cystic fibrosis, pulmonologist) or has consulted with such a specialist AND
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months