Camzyos (mavacamten) — Blue Cross Blue Shield of Alabama

symptomatic New York Heart Association (NYHA) class II-III obstructive hypertrophic cardiomyopathy (HCM)

Initial criteria

ONE of the following: the patient has been treated with the requested agent within the past 90 days (samples not approvable) OR the prescriber states the patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed OR the patient meets the following:
- diagnosis of symptomatic NYHA class II-III obstructive HCM
- left ventricular ejection fraction (LVEF) ≥ 55%
- no known infiltrative or storage disorder causing cardiac hypertrophy that mimics obstructive HCM (e.g., Fabry disease, amyloidosis, Noonan syndrome with LVH)
AND ONE of the following:
• Tried and had an inadequate response to ONE beta blocker OR had intolerance/hypersensitivity to ONE beta blocker OR has FDA labeled contraindication to ALL beta blockers
• Tried and had an inadequate response to a calcium channel blocker OR had intolerance/hypersensitivity to calcium channel blockers OR has FDA labeled contraindication to ALL calcium channel blockers
OR patient has another FDA labeled or compendia-supported indication for the requested agent and route of administration
AND if patient has an FDA labeled indication, ONE of the following: patient’s age is within FDA labeling OR there is support for use in patient’s age
AND prescriber is a cardiologist or has consulted with a cardiologist
AND patient has no FDA labeled contraindications to the requested agent

Patient previously approved for requested agent through prior authorization process
AND has demonstrated clinical benefit with the requested agent
AND has LVEF ≥ 50%
AND prescriber is a cardiologist or has consulted with a cardiologist
AND patient does not have any FDA labeled contraindications to the requested agent

12 months