Corlanor — Blue Cross Blue Shield of Oklahoma

Initial criteria

• 1. ONE of the following:
• A. The requested agent is eligible for continuation of therapy AND prescriber states the patient has been treated with the requested agent within the past 90 days (starting on samples not approvable) AND is at risk if therapy is changed OR
• B. BOTH of the following:
• 1. ONE of the following:
• A. Diagnosis of stable symptomatic heart failure (NYHA Class II-IV) due to dilated cardiomyopathy AND BOTH of (1) patient in sinus rhythm AND (2) patient has elevated heart rate OR
• B. Diagnosis of stable symptomatic chronic heart failure (NYHA Class II-IV) AND ALL of the following:
• • Left ventricular ejection fraction (LVEF) ≤ 35%
• • In sinus rhythm
• • Resting heart rate ≥ 70 beats per minute
• • ONE of the following:
• A. BOTH of (1) currently treated with a maximally tolerated beta blocker AND (2) 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: (A) Diagnosis of inappropriate sinus tachycardia (IST) or chronic nonparoxysmal sinus tachycardia AND (B) IST is symptomatic OR
• D. The patient has another FDA labeled indication for the requested agent and route of administration
• 2. If the patient has an FDA labeled indication, ONE of the following:
• A. Patient age is within FDA labeling for the requested indication OR
• B. Support exists for using the requested agent for patient's age OR
• C. Patient has another indication supported in compendia for the requested agent and route of administration
• 3. Prescriber is a specialist in the area (e.g., cardiologist) or has consulted with a specialist in the area of the patient’s diagnosis
• 4. Patient does NOT have any FDA labeled contraindications to the requested agent
• Compendia Allowed: AHFS or DrugDex 1, 2a, or 2b level of evidence
• Alternate approval (NM Fully Insured or NM HIM): ALL of the following:
• • No FDA labeled contraindications AND
• • Requested indication is a rare disease AND
• • ONE of the following: (A) another FDA labeled indication OR (B) indication supported in compendia for the requested agent and route of administration
• Alternate approval (Ohio Fully Insured or HIM Shop): ALL of the following:
• • Member resides in Ohio
• • Plan is Fully Insured or HIM Shop (SG)
• • No FDA labeled contraindications
• • ONE of the following:
• A. Another FDA labeled indication for requested agent and route of administration OR
• B. Indication supported in compendia OR
• C. Prescriber submitted TWO acceptable journal articles from JAMA, NEJM, or Lancet showing generally safe and effective use

Reauthorization criteria

• 1. Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• 2. Patient has experienced clinical benefit with the requested agent
• 3. Prescriber is a specialist in the area (e.g., cardiologist) or has consulted with a specialist in the patient’s diagnosis area
• 4. Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months