Alyftrek (vanzacaftor/tezacaftor/deutivacaftor) — CareFirst (Caremark)
Cystic fibrosis (CF) in patients with at least one F508del mutation or another responsive CFTR gene mutation
Initial criteria
- Prescribed by or in consultation with a pulmonologist
- Genetic testing was conducted to detect a mutation in the CFTR gene
- Member has one of the listed CFTR gene mutations from the policy
- Member age ≥ 6 years
- Alyftrek will not be used in combination with another CFTR modulator (e.g., Kalydeco, Trikafta)
Reauthorization criteria
- Member is experiencing benefit from therapy as evidenced by disease stability or disease improvement (e.g., improvement in FEV1 from baseline)
Approval duration
12 months