CurrentAvMedPolicy N/A

Verquvo (vericiguat) — Pharmacy Prior Authorization / Coverage Criteria

Form and clinical criteria governing pharmacy prior authorization and step-edit requests for Verquvo (vericiguat) for AvMed members; applies to prescribers seeking coverage for the drug.

Policy Summary

PayerAvMed

PolicyPharmacy Prior Authorization / Coverage Criteria for Verquvo (vericiguat)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed pharmacy PA/step-edit request form with required documentation (including EF within 12 months, verification of standard-of-care therapy, and recent hospitalization or IV diuretic records) and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30quantity limit per 30 days

>=18minimum patient age

<45%ejection fraction requirement

>100systolic BP min

6 morecent HF hospitalization

Coverage Criteria for Verquvo (vericiguat)

Initial Therapy — Covered when ALL of the following are met

Covered when ALL of the following are met

Main approval criteria

Prescriber and age: Prescribed by or in consultation with a cardiologist AND member is 18 years of age or older
Prescriber signature required on form; supporting documentation required
Diagnosis and severity: Chronic heart failure classified by NYHA functional class II-IV
Member must be stabilized on guideline-directed medical therapy including Entresto (see therapy requirements)
Standard of care background therapy: Member is stabilized on standard of care defined as Entresto PLUS one of the following: ACE inhibitor or ARB, beta-blocker, or spironolactone (verification via chart notes or pharmacy paid claims)

Policy Summary

PayerAvMed

PolicyPharmacy Prior Authorization / Coverage Criteria for Verquvo (vericiguat)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Verification required (chart notes or pharmacy paid claims)

Ejection fraction < 45% assessed within the past 12 monthsEF <45%

EF documentation must be submitted

Hemodynamics and recent decompensation: Member's systolic blood pressure is > 100 mmHg AND member has had a prior heart failure hospitalization within the past 6 months OR required outpatient IV diuretic therapy for heart failure within the past 3 monthsBP >100 mmHg

Hospitalization or outpatient IV diuretic documentation must be submitted

Safety: Member is not pregnant AND will not use Adempas (riociguat) in combination with vericiguat

Concurrent use with Adempas and pregnancy preclude coverage

Operational documentation requirement: All documentation supporting each checked clinical criterion (lab results, diagnostics, chart notes, pharmacy paid claims) must be provided or request may be denied

Use of samples to initiate therapy does not meet criteria; incomplete requests may be delayed or denied

Coverage is conditioned on patient safety and contraindications. The member must not be pregnant and must not use Adempas (riociguat) in combination with vericiguat. Documentation that the member is not pregnant and confirmation that Adempas will not be used concurrently must be provided with the prior authorization request. Use of samples to initiate therapy does not satisfy step-edit or prior authorization requirements.

Initial Authorization Requirements

Initial authorization — Initial coverage requires all criteria below.

Initial coverage requires all criteria below.

Initial vericiguat authorization: See Initial Therapy — Covered when ALL of the following are met for full nested requirements

Approval contingent on meeting and documenting every criterion listed in the Initial Therapy criteria set

Provider Actions & Required Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required for Verquvo. Complete the pharmacy PA/step-edit request form and fulfill all required criteria. Incomplete, incorrect, or illegible forms (including missing phone/fax/identifiers) may delay or result in denial of the authorization.

Fax completed form to 1-305-671-0200
Use of samples to initiate therapy does not meet step edit/preauthorization criteria
Previous therapies will be verified through pharmacy paid claims or submitted chart notes

Step Therapy

Step / Standard-of-Care Requirement

Approval requires that the member be stabilized on specified standard-of-care therapy in combination with Entresto. Documentation (chart notes or pharmacy paid claims) must verify current use of the required agents.

Required concurrent therapies (must be used WITH Entresto): ACE inhibitor or ARB; Beta-blocker; Spironolactone

Documentation Required

Required Supporting Documentation

All documentation supporting each checked clinical criterion must be provided. Missing labs, diagnostics, chart notes, or verification may result in denial.

Provide lab results, diagnostic reports, chart notes, or other verification for: NYHA classification, ejection fraction measurement (EF < 45% within past 12 months), systolic blood pressure (>100 mmHg), recent HF hospitalization (within 6 months) or outpatient IV diuretic therapy (within 3 months)
Documentation verifying stabilization on standard-of-care agents (chart notes or pharmacy paid claims)

Documentation Required

Signature and Contact Information

Prescriber must sign and clearly print name on the request form; preprinted stamps are not valid. Include complete prescriber contact and identification information to avoid delays.

Prescriber signature (hand-signed) and date required
Prescriber name, office contact name, fax number, and DEA or NPI number must be provided
Member name, AvMed ID number, and date of birth must be included

Documentation Required

Completeness and Documentation

Completeness and accuracy of the form is the responsibility of the submitting office. If information is incomplete, incorrect, or illegible the authorization process can be delayed or denied.

All required fields on the drug information section (form/strength, dosing, length of therapy, diagnosis, ICD code, weight, quantity limit) should be completed
Quantity limit: 30 tablets per 30 days
Do not rely on sample use to satisfy step-edit or prior authorization criteria

Coding, Clinical Thresholds, and Key Values

Quantity LimitsmixedCovered

Quantity limit

30 tablets per 30 days

inv-04: Ejection Fraction — < 45% (assessed within past 12 months)

Ejection fraction requirementEF < 45% assessed within the past 12 months

Documentation neededSubmit EF measurement report or chart note documenting EF within 12 months

Related criteriaApplies with NYHA class II-IV and stabilization on Entresto plus required background therapy

inv-05: Systolic blood pressure — > 100 mmHg

Systolic blood pressure minimum> 100 mmHg

Measurement timingRecent clinic blood pressure reading required and documented on request

ContextRequired alongside EF <45% and recent decompensation criteria

Dispensing Limits

inv-15: Verquvo (vericiguat) — 30 tablets

Quantity limit30 tablets per 30 days

Request form fieldQuantity Limit noted on drug information section of PA form

VerificationPlan-specific coverage may vary; non-formulary drugs may require medical necessity documentation

Definitions and Functional Class

inv-12: NYHA class II-IV — functional class requirement

NYHA functional class requirementNYHA class II-IV

Role in approvalMember must have CHF classified as NYHA II-IV and be stabilized on guideline-directed therapy

VerificationStabilization on Entresto plus ACE inhibitor/ARB or beta-blocker or spironolactone must be verified by chart notes or pharmacy paid claims

Background

Vericiguat (Verquvo) is indicated for patients with chronic heart failure with reduced ejection fraction who remain symptomatic despite guideline-directed therapy. Coverage requires that the patient be NYHA class II–IV, stabilized on guideline-directed medical therapy defined as Entresto plus one of an ACE inhibitor or ARB, beta-blocker, or spironolactone, have an ejection fraction < 45% assessed within the past 12 months, a systolic blood pressure > 100 mmHg, and recent evidence of decompensation (heart failure hospitalization within the past 6 months or outpatient IV diuretic therapy within the past 3 months). Chart notes or pharmacy paid claims must verify prior therapies and documentation of hospitalization or IV therapy must be submitted with the request.

Step Therapy Requirements

Step	Requirement
1
Member must be stabilized on Entresto plus one of the following: ACE inhibitor or ARB, beta-blocker, or spironolactone (verification via chart notes or pharmacy paid claims)