vericiguat — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following: (A) The requested agent is eligible for continuation of therapy AND 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 chronic heart failure (NYHA Class II–IV) AND ALL of the following: (1) The patient has a left ventricular ejection fraction (LVEF) < 45% AND (2) ONE of the following: (A) Hospitalization for heart failure within the past 6 months OR (B) Use of outpatient IV diuretics for heart failure within the past 3 months OR (C) The patient has another FDA labeled indication for the requested agent and route of administration OR (D) The patient has another indication supported in compendia for the requested agent and route of administration)
• If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support for using the requested agent for the patient’s age for the requested indication
• The prescriber is a specialist in cardiology or has consulted a cardiologist
• The patient does NOT have any FDA labeled contraindications to Verquvo
• Compendia allowed: AHFS or DrugDex 1, 2a, or 2b level of evidence
• Additional Ohio Fully Insured/HIM Shop exception: 1) Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND BOTH of the following: (A) The patient does NOT have any FDA labeled contraindications AND (B) ONE of the following: (1) Has another FDA labeled indication OR (2) Has another compendia-supported indication OR (3) Prescriber has submitted two peer-reviewed journal articles supporting proposed use. Accepted designs include randomized, double blind, placebo controlled clinical trials. Case studies not acceptable.

Reauthorization criteria

• The patient has been previously approved for Verquvo through the plan’s prior authorization process
• The patient has had clinical benefit with Verquvo
• The prescriber is a specialist in cardiology or has consulted a cardiologist
• The patient does NOT have any FDA labeled contraindications to Verquvo

Approval duration

12 months