vericiguat — Blue Cross Blue Shield of Texas

Initial criteria

• ONE of the following: (A) continuation of therapy: the prescriber states the 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) the patient has a diagnosis of symptomatic chronic heart failure (NYHA Class II-IV) AND the patient has a left ventricular ejection fraction (LVEF) < 45% AND ONE of the following: hospitalization of heart failure within the past 6 months OR use of outpatient IV diuretics for heart failure within the past 3 months
• OR the patient has another FDA labeled indication for the requested agent and route of administration OR has another indication supported in compendia for the requested agent and route of administration
• If the patient has an FDA labeled indication, ONE of the following: the patient’s age is within FDA labeling for the requested indication; OR 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 specialist
• The patient does NOT have any FDA labeled contraindications to the requested agent
• Compendia Allowed: AHFS or DrugDex level 1, 2a, or 2b
• Alternate approval: member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND patient has no FDA labeled contraindications AND ONE of the following: (1) another FDA labeled indication; (2) another indication supported in compendia; OR (3) prescriber submitted two peer-reviewed journal articles (JAMA, NEJM, Lancet, etc.) supporting proposed use as safe and effective

Reauthorization criteria

• Patient previously approved for the requested agent through the plan’s Prior Authorization process
• Patient has had clinical benefit with the requested agent
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist) OR has consulted with such specialist
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months