Camzyos (mavacamten) — Blue Cross Blue Shield of Kansas

Initial criteria

• ONE of the following:
• A. The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR
• B. 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
• C. The patient has a diagnosis of symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy (HCM) AND ALL of the following:
• 1. A left ventricular ejection fraction (LVEF) ≥ 55% AND
• 2. 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
• 3. ONE of the following:
• A. The patient has ONE of the following:
• 1. Tried and had an inadequate response to ONE beta blocker OR
• 2. An intolerance or hypersensitivity to ONE beta blocker OR
• 3. An FDA labeled contraindication to ALL beta blockers OR
• B. The patient has ONE of the following:
• 1. Tried and had an inadequate response to ONE calcium channel blocker OR
• 2. An intolerance or hypersensitivity to ONE calcium channel blocker OR
• 3. An FDA labeled contraindication to ALL calcium channel blockers OR
• D. The patient has another FDA labeled indication for the requested agent and route of administration OR
• E. The patient has another indication that is supported in compendia for the requested agent and route of administration AND
• 2. 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 AND
• 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
• 4. The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
• 2. The patient has had clinical benefit with the requested agent AND
• 3. The patient has a left ventricular ejection fraction (LVEF) ≥ 50% AND
• 4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
• 5. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months