Effective immediately, Harvard Pilgrim is now covering the medication Orkambi with prior authorization. In July 2015, the FDA approved Orkambi (ivacaftor/lumacaftor), an oral agent that targets a specific subgroup of patients with cystic fibrosis.
Orkambi is indicated for treating patients 12 years and older, who have two copies of the F508del gene mutation. Having two copies of this mutation, one inherited from each parent, occurs in approximately half of the cystic fibrosis population in the U.S. In patients for whom the genotype is unknown, an FDA-approved test should be used to detect the presence of the patient-specific mutation.
Orkambi will be covered on the Premium formularies only, at the highest tier (Tier 3 on the 3-Tier and Tier 4 on the 4-Tier). Harvard Pilgrim’s Orkambi Clinical Review Criteria detail the requirements that must be met in order to obtain prior authorization. To request prior authorization, please complete the Orkambi Medication Request Form and fax it to MedImpact Healthcare Systems at 888-807-6643.
For more information, please visit the Pharmacy section of Harvard Pilgrim’s provider website or call Clinical Pharmacy Services at 617-509-1786.