Medicare AdvantagePrior AuthMedium impact
CFTR Modulators (New)
Humana·Pulmonology, Pediatrics, Family Medicine +1 more·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has established a new prior authorization policy for CFTR modulators (cystic fibrosis medications) including Trikafta, Alyftrek, Kalydeco, Symdeko, and Orkambi. All requests require documentation of cystic fibrosis diagnosis, CFTR gene mutation testing, and specialist consultation, with Trikafta being the preferred first-line therapy.
Action Required
By January 1, 2026: Billing team must implement prior authorization requirements for all CFTR modulator prescriptions (Trikafta, Alyftrek, Kalydeco, Symdeko, Orkambi). Ensure providers document: 1) Cystic fibrosis diagnosis, 2) CFTR gene mutation testing results showing responsive mutation, 3) Treatment by/consultation with pulmonologist or specialist, 4) For non-Trikafta medications, document prior treatment failure, contraindication, or intolerance to Trikafta. Update pharmacy benefit management system to flag these medications for prior auth review.