Camzyos — Blue Cross Blue Shield of New Mexico

Initial criteria

• ONE of the following: (A) 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 NYHA class II–III obstructive HCM AND ALL of the following: (1) LVEF ≥ 55% AND (2) LVOT peak gradient ≥ 50 mmHg at rest or with provocation (Valsalva or post-exercise) AND (3) No known infiltrative or storage disorder causing cardiac hypertrophy that mimics obstructive HCM (e.g., Fabry disease, amyloidosis, Noonan syndrome with LVH) AND (4) ONE of the following: (A) Tried and had an inadequate response to a beta blocker OR (B) Intolerance or hypersensitivity to beta blockers OR (C) FDA labeled contraindication to ALL beta blockers AND (5) ONE of the following: (A) Tried and had an inadequate response to a calcium channel blocker OR (B) Intolerance or hypersensitivity to calcium channel blockers OR (C) FDA labeled contraindication to ALL calcium channel blockers OR (C) The patient has another FDA labeled indication for the requested agent and route of administration
• ONE of the following: (A) The patient’s age is within FDA labeling for the requested indication 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 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
• For Ohio Fully Insured or HIM Shop (SG) plans only: (1) Member resides in Ohio AND (2) Plan is Fully Insured or HIM Shop AND BOTH of the following: (A) Patient does NOT have FDA labeled contraindications AND (B) ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route of administration OR (2) The patient has another indication supported in compendia (non-oncology: DrugDex 1, 2A, 2B; AHFS-DI supportive; oncology: NCCN 1 or 2A; AHFS-DI supportive; DrugDex 1, 2A, 2B; Clinical Pharmacology; LexiDrugs A) OR (3) Prescriber submitted two peer-reviewed journal articles supporting the 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
• Patient has LVEF ≥ 50%
• 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