Alyftrek — Medical Mutual

Cystic Fibrosis (CF)

Initial criteria

Patient age ≥ 6 years
Medication is prescribed by or in consultation with a pulmonologist or a physician who specializes in the treatment of cystic fibrosis
Patient has at least ONE pathogenic or likely pathogenic CFTR gene variant listed in policy
Patient meets at least ONE of the following: (i) positive cystic fibrosis newborn screening test; OR (ii) family history of cystic fibrosis; OR (iii) clinical presentation consistent with signs and symptoms of cystic fibrosis
Patient has evidence of abnormal cystic fibrosis transmembrane conductance regulator function demonstrated by at least ONE of the following: (i) elevated sweat chloride test; OR (ii) two cystic fibrosis-causing CFTR mutations; OR (iii) abnormal nasal potential difference

Patient continues to meet all criteria for new starts
Patient has been using Alyftrek for at least 6 months
Patient has experienced an adequate response to therapy (e.g. improvement in FEV1 and/or other lung function tests, improvement in sweat chloride, decrease in pulmonary exacerbations or infections, increase in weight, decrease in hospitalizations) compared to baseline

initial 6 months; reauth 12 months