Verquvo — Blue Cross Blue Shield of Alabama

other FDA labeled indication

Initial criteria

ONE of the following:
• The requested agent is eligible for continuation of therapy AND ONE of the following:
– Patient has been treated with the requested agent (not including samples) within the past 90 days OR prescriber states patient has been treated with requested agent within the past 90 days and is at risk if therapy is changed
• OR the patient has a diagnosis of symptomatic chronic heart failure (NYHA Class II-IV) AND ALL of the following:
– Left ventricular ejection fraction (LVEF) <45%
– ONE of the following:
• Hospitalization for heart failure within the past 6 months OR
• Use of outpatient IV diuretics for heart failure within the past 3 months
• OR the patient has another FDA labeled indication for the requested agent and route of administration
• OR the patient has another indication supported in compendia (AHFS or DrugDex level 1 or 2a)
AND if the patient has an FDA labeled indication, ONE of the following:
– Patient’s age is within FDA labeling for the requested indication
– OR there is support for using the requested agent for the patient’s age for the requested indication
AND the prescriber is a specialist in the area of the diagnosis (e.g., cardiologist) or has consulted with a specialist
AND the patient does NOT have any FDA-labeled contraindications to the requested agent

• Patient was previously approved for the requested agent through the plan’s Prior Authorization process
• Patient has had clinical benefit with the requested agent
• Prescriber is a specialist in the area of the diagnosis (e.g., cardiologist) or has consulted with a specialist
• Patient does NOT have any FDA-labeled contraindications to the requested agent

12 months