Camzyos (mavacamten capsules) — Cigna

Initial criteria

• Patient age ≥ 18 years
• Patient has at least one symptom associated with obstructive hypertrophic cardiomyopathy AND has New York Heart Association Class II or III symptoms of heart failure
• Patient with left ventricular hypertrophy has maximal left ventricular wall thickness ≥ 15 mm OR has familial hypertrophic cardiomyopathy with maximal left ventricular wall thickness ≥ 13 mm
• Patient has a peak left ventricular outflow tract gradient ≥ 50 mmHg (at rest or after provocation [Valsalva maneuver or post exercise])
• Patient has a left ventricular ejection fraction ≥ 55%
• Medication is prescribed by a cardiologist

Reauthorization criteria

• Patient has been established on therapy for at least 8 months
• Patient age ≥ 18 years
• Currently or prior to starting therapy, patient has or has experienced at least one symptom associated with obstructive hypertrophic cardiomyopathy AND has New York Heart Association Class II or III symptoms of heart failure
• Patient with left ventricular hypertrophy has maximal left ventricular wall thickness ≥ 15 mm OR has familial hypertrophic cardiomyopathy with maximal left ventricular wall thickness ≥ 13 mm
• Patient has a peak left ventricular outflow tract gradient ≥ 50 mmHg (at rest or after provocation [Valsalva maneuver or post exercise])
• Patient has a left ventricular ejection fraction ≥ 55%
• Medication is prescribed by a cardiologist

Approval duration

Initial: 8 months; Reauth: 1 year