vericiguat — Blue Cross Blue Shield of New Mexico

Initial criteria

• ONE of the following: (A) The requested agent is eligible for continuation of therapy AND: 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 chronic heart failure (NYHA Class II-IV) AND ALL of the following: 1. The patient has a left ventricular ejection fraction (LVEF) < 45% AND 2. ONE of the following: (A) Hospitalization of heart failure within the past 6 months OR (B) Use of outpatient IV diuretics for heart failure within the past 3 months OR (C) The patient has another FDA labeled indication for the requested agent and route of administration OR (D) The patient has another indication that is supported in compendia for the requested agent and route of administration
• If the patient has an FDA labeled indication, 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 a specialist in the area
• The patient does NOT have any FDA labeled contraindications to the requested agent
• Compendia Allowed: AHFS or DrugDex 1, 2a, or 2b level of evidence
• For members residing in Ohio with Fully Insured or HIM Shop (SG) plans: BOTH of the following: (A) The patient does NOT have any FDA labeled contraindications to the requested agent 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 that is supported in compendia for the requested agent and route of administration OR 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) 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
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months