Provider Alert! Update to Kalydeco Clinical Prior Authorization Guidelines

Provider Alert!

Provider Alert! Update to Kalydeco Clinical Prior Authorization Guidelines

Attention: Pulmonologists

Effective Date: December 28, 2020

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health plan would like to inform network providers that effective December 28, 2020 Texas Medicaid will update the Kalydeco (ivacaftor) clinical prior authorization criteria. The changes reflect the newly FDA-approved indication for use in children age four months and older with at least one cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation responsive to Kalydeco. Previously, Kalydeco was approved only for children six months and older.

Navitus PA Form

Providers should use the updated Prior Authorization Kalydeco form. All prior authorization forms can be found on the Navitus website under Texas Medicaid section.

Next steps for providers: Providers should communicate these changes to their staff.

If you have any questions, please email Provider Network Management at:

For access to all provider alerts, log into: or

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