vericiguat — Blue Cross Blue Shield of Kansas

Initial criteria

• ONE of the following:
• A. The requested agent is eligible for continuation of therapy AND ONE of the following:
• 1. The patient has been treated with the requested agent (not samples) within the past 90 days OR
• 2. The prescriber states the patient has been treated with the requested agent (not 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 symptomatic chronic heart failure (NYHA Class II–IV) AND left ventricular ejection fraction <45% AND ONE of the following:
• i. Hospitalization for heart failure within the past 6 months OR
• ii. Use of outpatient intravenous diuretics for heart failure within the past 3 months OR
• B. The patient has another FDA labeled indication for the requested agent and route of administration
• 2. If the patient has an FDA labeled indication, ONE of the following:
• A. The patient’s age is within FDA labeling for that indication OR
• B. There is support for use of the requested agent for the patient’s age and indication OR
• C. The patient has another indication supported in compendia (AHFS or DrugDex 1 or 2a level of evidence)
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist) OR has consulted with such a specialist
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The patient was previously approved for the requested agent through the plan’s prior authorization process
• The patient has had clinical benefit with the requested agent
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist) OR has consulted with such a specialist
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months