ivabradine hcl oral solution — Blue Cross Blue Shield of Alabama

Initial criteria

• The requested agent is eligible for continuation of therapy AND one of the following:
• • The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR the prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed
• OR BOTH of the following apply:
• • The patient has a diagnosis of stable symptomatic heart failure (NYHA Class II-IV) due to dilated cardiomyopathy (DCM) AND BOTH of the following:
• – The patient is in sinus rhythm
• – The patient has an elevated heart rate
• OR The patient has a diagnosis of stable symptomatic chronic heart failure (NYHA Class II-IV) AND ALL of the following:
• – The patient has a left ventricular ejection fraction (LVEF) ≤ 35%
• – The patient is in sinus rhythm
• – The patient has a resting heart rate ≥ 70 beats per minute