CurrentBlue Cross Blue Shield - IowaPolicy 05.05.66

Camzyos (mavacamten) and Myqorzo (aficamten) for obstructive hypertrophic cardiomyopathy

Defines prior authorization, coverage criteria, documentation requirements, dosing/quantity limits, prescriber specialty, and continuation criteria for Camzyos (mavacamten) and Myqorzo (aficamten) for adults with symptomatic obstructive hypertrophic cardiomyopathy (oHCM). Applies to members when benefit exists and contract exclusions do not apply.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyCamzyos (mavacamten) and Myqorzo (aficamten) for obstructive hypertrophic cardiomyopathy

Policy CodePolicy 05.05.66

Change TypeRevised (April 2026)

Effective DateMay 14, 2026

Next Review Date

Key ActionPrior authorization is required; submit imaging, labs, chart notes or records documenting LV wall thickness, baseline LVEF, LVOT gradients, and prior medication use or intolerance; initial Camzyos approvals are for 3 months and Myqorzo for 12 months.

POLICY UPDATE CHANGES

Policy reviewed and revised April 2026; current effective date May 14, 2026.

2Drugs covered

3Initial approval requirements (major categories)

1Prescriber specialty required

3Camzyos initial approval duration (months)

Myqorzo initial/continuation approval duration (months)

Coverage Summary

Camzyos (mavacamten) and Myqorzo (aficamten) are indicated for treatment of adults with symptomatic New York Heart Association (NYHA) class II-III obstructive hypertrophic cardiomyopathy (oHCM) to improve functional capacity and symptoms. Coverage aligns with FDA-approved labeling, relevant guidelines, and standards of medical practice; the policy coverage stance is covered_with_criteria and is effective May 14, 2026.

Key thresholds and policy dates

Left ventricular wall thickness>= 15 mm (or >= 13 mm with familial HCM or positive genetic test)

Baseline LVEF (initial)>= 55%

Baseline LVEF (continuation)>= 50%

Baseline resting LVOT gradient> 30 mmHg (Myqorzo requirement)

Baseline Valsalva LVOT peak gradient>= 50 mmHg

Policy number05.05.66

Effective date2026-05-14

Last review2026-04-01

Initial Therapy — Camzyos (mavacamten)

Authorization of 3 months for Camzyos may be granted for treatment of obstructive hypertrophic cardiomyopathy when ALL of the following criteria are met:

ALL of the following

- Left ventricular wall thickness ≥ 15 mm anywhere in the left ventricle≥ 15 mm
- Left ventricular wall thickness ≥ 13 mm anywhere in the left ventricle in members with familial hypertrophic cardiomyopathy or in conjunction with a positive genetic test (e.g., MYH7, MYBPC3, TNNI3, TNNT2, TPM1, MYL2, MYL3, ACTC1 gene variants)≥ 13 mm
  familial HCM or positive genetic test

Initial Therapy — Myqorzo (aficamten)

Initial authorization — Myqorzo (aficamten)

Authorization of 12 months for Myqorzo may be granted when ALL of the following are met:

ALL of the following

Left ventricular wall thickness
- Left ventricular wall thickness of greater than or equal to 15 mm anywhere in the left ventricle
- Left ventricular wall thickness of greater than or equal to 13 mm anywhere in the left ventricle in members with familial hypertrophic cardiomyopathy or in conjunction with a positive genetic test (e.g., MYH7, MYBPC3, TNNI3, TNNT2, TPM1, MYL2, MYL3, ACTC1 gene variants)
Member has NYHA functional class II-III symptoms
LVOT gradient requirements

Continuation / Reauthorization Criteria

Continuation / Reauthorization — obstructive hypertrophic cardiomyopathy

Authorization of 12 months may be granted for continued treatment when ALL applicable criteria are met:

ALL of the following

Clinical response: The member achieved or maintained a positive clinical response to therapy (e.g., increase in pVO2, NYHA class reduction)
Examples provided
LVEF: Member has a left ventricular ejection fraction (LVEF) ≥ 50%>= 50%
Rifampin restriction: Member cannot use the requested medication concomitantly with rifampin (Myqorzo only)

Provider Actions & Documentation Requirements

Prior Authorization

Prior authorization required

Prior authorization is required. Submit imaging reports, labs, chart notes or medical records documenting left ventricular (LV) wall thickness, baseline left ventricular ejection fraction (LVEF), baseline resting and Valsalva LVOT gradients (where applicable), and prior medication trials or documentation of intolerance. Initial approvals: Camzyos (mavacamten) — 3 months; Myqorzo (aficamten) — 12 months.

Documentation Required

Required documentation for initial requests

Provide imaging reports, laboratory results, chart notes or medical record documentation supporting LV wall thickness (≥15 mm, or ≥13 mm if familial HCM or with a positive genetic test), baseline LVEF ≥ 55%, baseline Valsalva LVOT peak gradient ≥ 50 mmHg (and baseline resting LVOT gradient ≥ 30 mmHg if applicable), and chart notes, medical records, or claims history documenting prior medication trials or clinical reasons to avoid therapy.

Applicable Codes & Identifiers

Policy identifiermixed

05.05.66

Policy # (internal identifier)

Clinical Evidence & References

Key references include the Camzyos and Myqorzo package inserts (Camzyos April 2025; Myqorzo December 2025), the 2024 AHA/ACC guideline, the 2023 ESC guideline, and pivotal clinical trials including EXPLORER-HCM (mavacamten) and the NEJM aficamten trial.

Definitions: NYHA functional class II denotes a slight limitation of physical activity and class III denotes a marked limitation of physical activity (classification documented in the Appendix); oHCM refers to obstructive hypertrophic cardiomyopathy.

Background

Both Camzyos (mavacamten) and Myqorzo (aficamten) are indicated to improve functional capacity and symptoms in adults with symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy (oHCM). Coverage and utilization management are aligned with FDA labeling and clinical practice standards, including prior authorization, documentation of diagnostic and functional criteria (e.g., LV wall thickness, baseline LVEF, LVOT gradients), prescriber specialty requirements, and continuation criteria.

Revision History

2026-04-01policy_reviewLatest

Policy reviewed and revised April 2026; no clinical policy statement changes; current effective date May 14, 2026; marked non-material.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyCamzyos (mavacamten) and Myqorzo (aficamten) for obstructive hypertrophic cardiomyopathy

Policy CodePolicy 05.05.66

Change TypeRevised (April 2026)

Effective DateMay 14, 2026

Next Review Date

On This Page

Member has NYHA functional class II-III symptoms

See Appendix for NYHA classification

Member must have a baseline left ventricular ejection fraction (LVEF) ≥ 55%>= 55%

Member must have a baseline Valsalva left ventricular outflow tract (LVOT) peak gradient ≥ 50 mmHg>= 50 mmHg

Member has experienced an inadequate response to a beta-adrenergic antagonist (e.g., atenolol, metoprolol) or a non-dihydropyridine calcium channel blocker (e.g., diltiazem, verapamil) at maximally tolerated dose, OR has an intolerance or contraindication to both therapies

Document prior medications tried and response; if therapy not advisable, provide clinical reason

Baseline resting left ventricular outflow tract (LVOT) gradient > 30 mmHg> 30 mmHg

Baseline Valsalva left ventricular outflow tract (LVOT) peak gradient ≥ 50 mmHg>= 50 mmHg

Prior therapy: Member has experienced an inadequate response to a beta-adrenergic antagonist (e.g., atenolol, metoprolol) or non-dihydropyridine calcium channel blocker (e.g., diltiazem, verapamil) at maximally tolerated dose OR has an intolerance or contraindication to both therapies

Myqorzo-specific restriction

Camzyos (mavacamten) and Myqorzo (aficamten) are considered not medically necessary when the specified coverage criteria are not met.

Imaging reports showing LV wall thickness (≥15 mm, or ≥13 mm with familial HCM/positive genetic test)
Baseline LVEF ≥ 55% (chart/lab report)
Baseline Valsalva LVOT peak gradient ≥ 50 mmHg (and resting LVOT gradient ≥ 30 mmHg if applicable)
Documentation of prior beta-blocker or non‑dihydropyridine CCB trial at maximally tolerated dose, or intolerance/contraindication

Documentation Required

Required documentation for continuation requests

For continuation/reauthorization, provide chart notes or medical records demonstrating a positive clinical response to therapy (for example increased peak oxygen consumption [pVO2] or reduction in NYHA class) and documentation that LVEF is ≥ 50%. For Myqorzo, also document that the member is not using rifampin concomitantly.

Evidence of positive clinical response (e.g., increase in pVO2, NYHA class reduction)
LVEF ≥ 50% on recent assessment
For Myqorzo: documentation of no concomitant rifampin use

Billing Rule

Quantity limits

Quantity limits apply and dosing should follow FDA-recommended dosing and titration. Camzyos capsules available in 2.5, 5, 10, and 15 mg with a standard limit of 1 capsule per day; Myqorzo tablets available in 5, 10, 15, and 20 mg with a standard limit of 1 tablet per day.

Camzyos (mavacamten) capsules: 2.5 mg, 5 mg, 10 mg, 15 mg — standard limit = 1 capsule/day
Myqorzo (aficamten) tablets: 5 mg, 10 mg, 15 mg, 20 mg — standard limit = 1 tablet/day
Follow FDA-recommended dosing/titration

Denial Risk

Denial if criteria unmet

Claims may be denied as not medically necessary if the member does not meet the specified diagnostic, NYHA functional class, LVOT gradient, LVEF, or prior-therapy criteria required for approval.

Documentation Required

Prescriber specialty requirement

The requested medication must be prescribed by or in consultation with a cardiologist.