Corlanor — Blue Cross Blue Shield of Montana

Initial criteria

• ONE of the following:
• A. Continuation of therapy: The prescriber states the patient has been treated with the requested agent within the past 90 days (starting on samples is not approvable) 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 (DCM) AND BOTH:
• • The patient is in sinus rhythm AND
• • The patient has an elevated heart rate OR
• B. The patient has stable symptomatic chronic heart failure (NYHA Class II‑IV) AND ALL:
• • left ventricular ejection fraction (LVEF) ≤ 35% AND
• • patient is in sinus rhythm AND
• • resting heart rate ≥ 70 bpm AND
• • ONE of:
• A. BOTH: patient is currently treated with a 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 of the following:
• • diagnosis of inappropriate sinus tachycardia (IST) or chronic nonparoxysmal sinus tachycardia AND
• • IST is symptomatic OR
• D. The patient has another FDA‑labeled indication for the requested agent and route of administration AND
• 2. If the patient has an FDA‑labeled indication, ONE of:
• A. age within FDA labeling for the requested indication OR
• B. support for use in patient’s age for that indication OR
• C. another indication supported in compendia (AHFS or DrugDex level 1, 2a, or 2b) for the agent and route of administration AND
• 3. Prescriber is a specialist (e.g., cardiologist) or has consulted with one AND
• 4. Patient has no FDA‑labeled contraindications to ivabradine.
• Additional special approvals:
• • For BCBS NM Fully Insured or NM HIM members: patient has no FDA‑labeled contraindications AND indication is a rare disease AND (has FDA‑labeled indication OR compendia‑supported indication).
• • For Ohio Fully Insured or HIM Shop (SG) members: patient resides in Ohio, plan is eligible, patient has no FDA‑labeled contraindications, AND ONE of: (FDA‑labeled indication, compendia‑supported indication, or two peer‑reviewed journal articles supporting the proposed use).

Reauthorization criteria

• 1. Patient was previously approved through plan PA process AND
• 2. Patient has had clinical benefit with the requested agent AND
• 3. Prescriber is a specialist (e.g., cardiologist) or has consulted with one AND
• 4. Patient has no FDA‑labeled contraindications.

Approval duration

12 months