ivabradine hcl — Blue Cross Blue Shield of New Mexico

Initial criteria

• 1. ONE of the following: A. The requested agent is eligible for continuation of therapy AND the following: - 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. 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 DCM AND BOTH of the following: - The patient is in sinus rhythm AND - The patient has an elevated heart rate OR B. The patient has a diagnosis of stable symptomatic chronic heart failure (NYHA Class II-IV) AND ALL of the following: - LVEF ≤ 35% AND - Sinus rhythm AND - Resting heart rate ≥ 70 bpm AND - ONE of the following: A. BOTH of the following: 1. Currently treated with a maximally tolerated beta blocker AND 2. Will continue beta blocker therapy OR B. Has an intolerance or hypersensitivity to ONE beta blocker OR C. Has an FDA labeled contraindication to ALL beta blockers OR C. BOTH of the following: A. Has a diagnosis of inappropriate sinus tachycardia (IST) or chronic nonparoxysmal sinus tachycardia AND B. IST is symptomatic OR D. Has another FDA labeled indication for the requested agent and route of administration 2. If patient has an FDA labeled indication, then ONE of the following: A. Age is within FDA labeling for the indication OR B. Supported use in patient’s age for indication OR C. Other compendia-supported indication with requested route of administration 3. Prescriber is a specialist in the area of the diagnosis (e.g., cardiologist) or has consulted with such a specialist AND 4. Patient has no FDA labeled contraindications to the requested agent Compendia allowed: AHFS or DrugDex 1, 2a, or 2b.
• Additional approval paths: - For BCBS NM Fully Insured or NM HIM member: patient has no labeled contraindications AND indication is a rare disease AND ONE of the following: 1. Another FDA labeled indication OR 2. Another compendia-supported indication. - For Ohio Fully Insured or HIM Shop (SG) member: ALL of the following: - Residence in Ohio - Plan is Fully Insured or HIM Shop (SG) - No FDA labeled contraindications - ONE of the following: 1. Another FDA labeled indication OR 2. Another compendia-supported indication OR 3. Prescriber has submitted TWO articles from major peer-reviewed journals supporting safe and effective use.

Reauthorization criteria

• 1. Patient has been previously approved for the requested agent through plan’s prior authorization process AND 2. Patient has had clinical benefit with the requested agent AND 3. Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist) or has consulted with such a specialist AND 4. Patient has no FDA labeled contraindications to the requested agent.

Approval duration

12 months