Trikafta (elexacaftor/tezacaftor/ivacaftor) — Medica

Cystic Fibrosis

Initial criteria

age ≥ 2 years
Patient has at least ONE mutation in the CFTR gene that is considered pathogenic or likely pathogenic (explicitly listed in policy)
Patient meets at least ONE of the following: positive cystic fibrosis newborn screening test OR family history of cystic fibrosis OR clinical presentation consistent with cystic fibrosis (e.g., meconium ileus, sino-pulmonary symptoms, bronchiectasis, sinusitis, failure to thrive, pancreatic insufficiency)
Patient has evidence of abnormal CFTR function as shown by at least ONE of the following: elevated sweat chloride test OR two cystic fibrosis–causing CFTR mutations OR abnormal nasal potential difference
Prescribed by or in consultation with a pulmonologist or physician specializing in cystic fibrosis

1 year