Verquvo — Blue Cross Blue Shield of Montana

Initial criteria

• The requested agent is eligible for continuation of therapy AND ALL of the following: - 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 The patient has a diagnosis of symptomatic chronic heart failure (NYHA Class II-IV) AND ALL of the following: - Left ventricular ejection fraction (LVEF) < 45% AND ONE of the following: • Hospitalization of heart failure within the past 6 months OR • Use of outpatient IV diuretics for heart failure within the past 3 months OR The patient has another FDA labeled indication for the requested agent and route of administration OR 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: - Patient’s age is within FDA labeling for the requested indication OR - There is support for using the requested agent for the patient’s age for the requested indication
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist), or has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA labeled contraindications to the requested agent
• Additional approval for residents of Ohio with Fully Insured or HIM Shop (SG) plans if: - Patient does NOT have any FDA labeled contraindications to the requested agent AND - ONE of the following is met: • Patient has another FDA labeled indication for the requested agent and route of administration OR • Patient has another indication supported in compendia for the requested agent and route of administration OR • Prescriber submitted TWO peer-reviewed journal articles supporting proposed use as generally safe and effective

Reauthorization criteria

• The patient has been 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 a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months