Kalydeco (ivacaftor) — United Healthcare

Initial criteria

• Diagnosis of cystic fibrosis (CF)
• AND Documentation confirming that patient has at least one CFTR gene mutation responsive to Kalydeco (reference list from prescribing information)

Reauthorization criteria

• Documentation of positive clinical response to Kalydeco therapy (e.g., improved lung function, stable lung function)

Approval duration

12 months