Pharmacy Prior Authorization Criteria

Camzyos (mavacamten) - PA, NF

Indications for Prior Authorization

Camzyos (mavacamten)

• For diagnosis of Obstructive hypertrophic cardiomyopathy (HCM)
  Indicated for the treatment of adults with symptomatic New York Heart Association (NYHA) class II-III obstructive hypertrophic cardiomyopathy (HCM) to improve functional capacity and symptoms.

Criteria

Camzyos

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

• Diagnosis of obstructive hypertrophic cardiomyopathy (HCM)
AND
• Patient has New York Heart Association (NYHA) Class II or III symptoms (e.g., shortness of breath, chest pain)
AND
• Patient has a left ventricular ejection fraction of greater than or equal to 55%
AND
• Patient has valsalva left ventricular outflow tract (LVOT) peak gradient greater than or equal to 50 mmHg at rest or with provocation
AND
• Trial and failure, contraindication, or intolerance to both of the following at a maximally tolerated dose: [2]
• non-vasodilating beta blocker (e.g., bisoprolol, propranolol)
• calcium channel blocker (e.g., verapamil, diltiazem)
AND
• Prescribed by or in consultation with a cardiologist

Camzyos

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., improved symptom relief)
AND
• Patient has a left ventricular ejection fraction of greater than or equal to 50% [A, B, 1]
AND
• Prescribed by or in consultation with a cardiologist

Camzyos

Non Formulary (Initial Authorization)

Length of Approval: 6 Month(s)

• Diagnosis of obstructive hypertrophic cardiomyopathy (HCM)
AND
• Patient has New York Heart Association (NYHA) Class II or III symptoms (e.g., shortness of breath, chest pain)
AND
• Submission of medical records (e.g., chart notes) documenting patient has a left ventricular ejection fraction of greater than or equal to 55%
AND
• Submission of medical records (e.g., chart notes) documenting patient has valsalva left ventricular outflow tract (LVOT) peak gradient greater than or equal to 50 mmHg at rest or with provocation
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure, contraindication, or intolerance to both of the following at a maximally tolerated dose: [2]
• non-vasodilating beta blocker (e.g., bisoprolol, propranolol)
• calcium channel blocker (e.g., verapamil, diltiazem)
AND
• Prescribed by or in consultation with a cardiologist

Camzyos

Non Formulary (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., improved symptom relief)
AND
• Submission of medical records (e.g., chart notes) documenting patient has a left ventricular ejection fraction of greater than or equal to 50% [A, B, 1]
AND
• Prescribed by or in consultation with a cardiologist

P & T Revisions

2024-07-02, 2023-09-13, 2023-06-14, 2022-10-04, 2022-08-16, 2022-07-05

References

1. Camzyos prescribing information. MyoKardia, Inc. Brisbane, CA. April 2024.
2. Ommen SR, Mital S, Burke MA, et al. 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy. Circulation. 2020;142(25).

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End Notes

1. Patients may develop heart failure while taking CAMZYOS. Regular LVEF and Valsalva left ventricular outflow tract (LVOT) gradient assessment is required for careful titration to achieve an appropriate target Valsalva LVOT gradient, while maintaining LVEF ≥50% and avoiding heart failure symptoms. [1]
2. If LVEF <50% while taking Camzyos, interrupt treatment. [1]

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Revision History

• 2024-07-02: 2024 Annual Review - updated references
• 2023-09-13: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-06-14: 2023 Annual Review - no changes
• 2022-10-04: Addition of NF criteria
• 2022-08-16: Update to initial authorization duration and trial and failure criteria
• 2022-07-05: New program

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