ivabradine hcl tab — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following:
• A. The requested agent is eligible for continuation of therapy AND the patient has been treated with the requested agent (not just samples) within the past 90 days AND is at risk if therapy is changed OR
• B. BOTH of the following:
• 1. ONE of the following:
• A. The patient has a diagnosis of stable symptomatic heart failure (NYHA Class II-IV) due to dilated cardiomyopathy AND BOTH: (1) patient is in sinus rhythm AND (2) patient has an elevated heart rate OR
• B. The patient has a diagnosis of stable symptomatic chronic heart failure (NYHA Class II-IV) AND ALL: (1) left ventricular ejection fraction ≤ 35% AND (2) patient is in sinus rhythm AND (3) resting heart rate ≥ 70 beats per minute AND (4) ONE of: (A) BOTH: patient is currently treated with maximally tolerated beta blocker AND will continue beta blocker therapy OR (B) intolerance or hypersensitivity to ONE beta blocker OR (C) FDA labeled contraindication to ALL beta blockers OR
• C. BOTH: (1) patient has diagnosis of inappropriate sinus tachycardia or chronic nonparoxysmal sinus tachycardia AND (2) patient’s IST is symptomatic OR
• D. The patient has another FDA labeled indication for the requested agent and route of administration
• 2. If the patient has an FDA labeled indication, then ONE of the following: (A) age within FDA labeling OR (B) support for off-label age use OR (C) indication supported in compendia (AHFS or DrugDex 1, 2a, 2b)
• 3. Prescriber is a specialist in the area of diagnosis (e.g., cardiologist) or has consulted with one
• 4. Patient has no FDA labeled contraindications to requested agent
• Alternate approval paths:
• 1. For BCBS NM Fully Insured or NM HIM member: patient has no FDA labeled contraindications, and requested indication is a rare disease, and patient has FDA labeled indication or compendia-supported indication
• 2. For resident in Ohio, plan Fully Insured or HIM Shop (SG): patient has no FDA labeled contraindications, and patient has FDA labeled indication or compendia-supported indication, OR prescriber submitted two peer-reviewed journal articles supporting use

Reauthorization criteria

• 1. Patient previously approved for requested agent through plan’s Prior Authorization process
• 2. Patient has had clinical benefit with requested agent
• 3. Prescriber is a specialist in area of diagnosis or has consulted with one
• 4. Patient has no FDA labeled contraindications to requested agent

Approval duration

12 months