CurrentCignaPolicy N/A

Verquvo Drug Quantity Management Policy

Defines quantity limits, one-time override rules, and approval durations for Verquvo (vericiguat) 2.5 mg, 5 mg, and 10 mg tablets for Cigna-administered health benefit plans. Applies at point-of-sale; if quantity management rule not met, coverage determined by criteria and approvals are time-limited.

Policy Summary

PayerCigna

PolicyVerquvo Drug Quantity Management Policy

Policy CodePolicy N/A

Change TypeQuantity limit and override clarifications

Effective Date

Next Review Date

Key ActionIf the Drug Quantity Management rule is not met at point of service, coverage will be determined by the policy criteria and providers may request a one-time override when dose escalation criteria are met.

SourceLink

POLICY UPDATE CHANGES

Policy Statement was updated to clarify that 'one-time' overrides are provided for 30 days in duration.

Verquvo 2.5 mg and 5 mg tablets: Override criteria updated to approve 60 tablets at retail or 180 tablets at home delivery (previously 60 tablets at retail or home delivery).

Policy updated to reflect existing quantity limits when product obtained via home delivery.

Annual revisions with no criteria changes noted in prior years (04/06/2023, 04/22/2024).

3Product strengths covered

30Retail max tabs/Rx

Home delivery max/Rx

60/180One-time override (retail/home)

Coverage Summary

Verquvo (vericiguat) is covered with criteria for adults with symptomatic chronic heart failure and ejection fraction <45% following hospitalization for heart failure or need for outpatient IV diuretics. The policy defines quantity limits and one-time override rules for Verquvo 2.5 mg, 5 mg, and 10 mg tablets for Cigna-administered health benefit plans. Drug Quantity Limits apply at the point-of-sale; if the quantity rule is not met, coverage will be determined by the policy criteria and approvals provided for the durations noted.

Key quantity and scope summary

Product strengths covered2.5 mg, 5 mg, 10 mg (3 strengths)

Retail max tablets per Rx30 tablets per Rx for each strength

Home delivery max tablets per Rx90 tablets per Rx for each strength

One-time override quantity (retail/home)60 tablets (retail) or 180 tablets (home delivery); one-time overrides are 30 days in duration

Policy scope summaryDefines quantity limits, one-time override rules, and 30-day approval duration for Verquvo (vericiguat) 2.5 mg, 5 mg, and 10 mg tablets for Cigna-administered health benefit plans; applies at point-of-sale with coverage determined by criteria when limits are not met.

Drug Quantity Limits & One-time Overrides

Drug Quantity Limits and Override Approval Criteria

Per Rx product(s) is(are) covered as medically necessary when the following criteria is(are) met. Any other exception is considered not medically necessary.

Drug Quantity Limits apply at point of service; if rule not met, coverage determined by criteria below

Verquvo 2.5 mg tablets

ALL of the following
- Retail override: Approve a one-time override of 60 tablets at retail60 tablets
- Home delivery override: Approve a one-time override of 180 tablets at home delivery

Applicable Codes

NDC / product strength referencesNDC

No codes listed

Clinical Evidence & References

Prescribing Information: Verquvo tablets [Merck], May 2023.

Quantity-management policy intent: The Drug Quantity Management program is developed to promote the safe, effective, and economic use of Verquvo.

Background

Indication: Verquvo is indicated to reduce the risk of cardiovascular death and heart failure hospitalization in adults with symptomatic chronic heart failure and ejection fraction <45% following a hospitalization for heart failure or need for outpatient intravenous diuretics.

Policy intent: This Drug Quantity Management program is intended to promote the safe, effective, and economic use of Verquvo; if the Drug Quantity Management rule is not met at the point of service, coverage will be determined by the policy criteria and one-time overrides are provided for 30 days.

One-time override: A temporary approval provided for 30 days to allow additional quantity for dose escalation scenarios as specified in the policy.

Revision History

04/09/2025annual_revisionLatest

Annual revision documenting prior updates; policy status current as of last review.

04/22/2024revised

Policy Statement clarified that one-time overrides are provided for 30 days in duration.

04/22/2024revised

Override criteria for Verquvo 2.5 mg and 5 mg updated to approve 60 tablets at retail or 180 tablets at home delivery (previously 60 tablets at retail or home delivery).

Policy Summary

PayerCigna

PolicyVerquvo Drug Quantity Management Policy

Policy CodePolicy N/A

Change TypeQuantity limit and override clarifications

Effective Date

Next Review Date

SourceLink

On This Page

Verquvo 5 mg tablets

ALL of the following
- Retail override: Approve a one-time override of 60 tablets at retail60 tablets
- Home delivery override: Approve a one-time override of 180 tablets at home delivery180 tablets

Verquvo 10 mg tablets: No overrides recommended

Prior Authorization

Quantity limit enforcement at point of service

If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the policy criteria and approvals provided for the durations noted; providers may request a one-time override when dose escalation criteria are met.

One-time overrides are provided for 30 days in duration.
Overrides apply for specified dose-escalation scenarios (2.5 mg -> 5 mg and 5 mg -> 10 mg).

Documentation Required

Dose escalation justification

Providers should document dose change from 2.5 mg to 5 mg or from 5 mg to 10 mg when requesting a one-time override to support the override approval.

Document dose increase from 2.5 mg to 5 mg when requesting an override.
Document dose increase from 5 mg to 10 mg when requesting an override.

Billing Rule

Maximum quantity per Rx by channel

Retail maximum quantity per Rx = 30 tablets for each strength; Home Delivery maximum quantity per Rx = 90 tablets for each strength; one-time overrides permit 60 (retail) or 180 (home delivery) tablets for permitted dose escalations.

Retail max = 30 tablets
Home Delivery max = 90 tablets
One-time override permitted quantities: 60 tablets (retail) or 180 tablets (home delivery)

prior to 04/06/2023clarified

Policy updated to reflect existing quantity limits when product is obtained via home delivery; affirms retail maximum 30 tablets/Rx and home delivery maximum 90 tablets/Rx with overrides aligned to those channels.

04/06/2023 / 04/22/2024revised

Historical annual revisions noted with no criteria changes in those review cycles.