Camzyos (mavacamten) — Blue Cross Blue Shield of Texas

Initial criteria

• ONE of the following: (A) Prescriber states patient has been treated with the requested agent (not starting on samples) within the past 90 days and is at risk if therapy is changed OR (B) Patient has a diagnosis of symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy AND ALL of the following:
• - Left ventricular ejection fraction (LVEF) ≥ 55%
• - Left ventricular outflow tract (LVOT) peak gradient ≥ 50 mmHg at rest or with provocation (Valsalva or post-exercise)
• - No known infiltrative or storage disorder causing cardiac hypertrophy that mimics obstructive HCM (e.g., Fabry disease, amyloidosis, Noonan syndrome with left ventricular hypertrophy)
• - ONE of the following regarding beta blockers: (A) Tried and had inadequate response OR (B) Intolerance or hypersensitivity OR (C) FDA labeled contraindication to ALL beta blockers
• - ONE of the following regarding calcium channel blockers: (A) Tried and had inadequate response OR (B) Intolerance or hypersensitivity OR (C) FDA labeled contraindication to ALL calcium channel blockers
• (C) Patient has another FDA labeled indication for the requested agent and route of administration
• AND ONE of the following: (A) 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
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist) or has consulted with a specialist
• Patient does NOT have any FDA labeled contraindications to the requested agent
• For Ohio Fully Insured or HIM Shop (SG) members: BOTH of the following must apply: (A) Patient has no FDA labeled contraindications AND ONE of the following: (1) Another FDA labeled indication for requested agent and route of administration OR (2) Another indication supported in compendia OR (3) Two peer-reviewed journal articles supporting use

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s prior authorization process
• Patient has had clinical benefit with the requested agent
• Left ventricular ejection fraction (LVEF) ≥ 50%
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist) or has consulted with a specialist
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months