mavacamten — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following: (A) 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 (B) The patient has a diagnosis of symptomatic NYHA class II–III obstructive HCM AND ALL of the following: 1. Left ventricular ejection fraction (LVEF) ≥ 55% AND 2. Left ventricular outflow tract (LVOT) peak gradient ≥ 50 mmHg at rest or with provocation (Valsalva or post-exercise) AND 3. No known infiltrative or storage disorder causing cardiac hypertrophy that mimics obstructive HCM (e.g., Fabry disease, amyloidosis, Noonan syndrome with left ventricular hypertrophy) AND 4. ONE of the following: (A) Tried and had inadequate response to a beta blocker OR (B) Intolerance or hypersensitivity to beta blocker therapy OR (C) FDA-labeled contraindication to ALL beta blockers AND 5. ONE of the following: (A) Tried and had inadequate response to a calcium channel blocker OR (B) Intolerance or hypersensitivity to calcium channel blocker therapy OR (C) FDA-labeled contraindication to ALL calcium channel blockers OR (C) Patient has another FDA labeled indication for the requested agent and route of administration
• Patient’s age is within FDA labeling for the requested indication OR there is support for use for the patient’s age for the indication
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist) or has consulted with a specialist
• Patient does NOT have any FDA-labeled contraindications to the requested agent

Reauthorization criteria

• Patient previously approved for the requested agent through the plan’s Prior Authorization process
• Patient has had clinical benefit with the requested agent
• Left ventricular ejection fraction (LVEF) ≥ 50%
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist) or has consulted with a specialist
• Patient does NOT have any FDA-labeled contraindications to the requested agent

Approval duration

12 months