Camzyos (mavacamten) prior authorization / medical necessity
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Policy governing prior authorization and medical necessity criteria for Camzyos (mavacamten) for adults with symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy; applies to Colorado Rocky Mountain Health Plans pharmacy benefit and prescribers seeking coverage.
Clarified that left ventricular ejection fraction and LVOT measurements must be obtained prior to starting Camzyos therapy.
Added explicit prohibition on use in combination with another cardiac myosin inhibitor (e.g., Myqorzo/aficamten).
Revised reauthorization left ventricular ejection fraction threshold to ≥ 50% (from prior threshold).
Coverage Criteria for Camzyos (mavacamten)
Initial Authorization
Covered when ALL of the following are met:
Measurements must be obtained prior to starting Camzyos therapy.
Maximally tolerated dose required.
Reauthorization
Covered when ALL of the following are met:
Combination therapy exclusion: Camzyos (mavacamten) must not be used in combination with another cardiac myosin inhibitor. Concurrent therapy with agents such as Myqorzo (aficamten) is explicitly prohibited.
Not medically necessary / unsupported situations: Therapy is not supported when the patient does not meet the initial or reauthorization criteria. Examples include: insufficient pre-treatment measurements (e.g., LVEF <55% prior to starting therapy for initial requests), insufficient left ventricular outflow tract gradient (e.g., LVOT peak gradient <50 mmHg at rest or with provocation), lack of required trial or intolerance documentation for a non-vasodilating beta blocker or a nondihydropyridine calcium channel blocker, lack of documented positive clinical response on reauthorization, or when Camzyos is prescribed in combination with another cardiac myosin inhibitor.
Coding and Clinical Thresholds
| ICD-10 | Diagnosis codes may be used for automated approvals and are referenced generally; specific ICD-10 codes not enumerated in document. |
Provider Actions, Documentation, and Denial Triggers
Prior authorization required; 12‑month approvals
Prior authorization is required for Camzyos and will be approved when all initial or reauthorization criteria are met. When approved, authorizations are issued for a 12‑month period.
Step therapy: trial of beta blocker OR nondihydropyridine CCB required
Before initiating Camzyos, document an inadequate response, intolerance, failure, or contraindication to at least one non‑vasodilating beta blocker OR one nondihydropyridine calcium channel blocker, given at a maximally tolerated dose.
- Examples of non‑vasodilating beta blockers cited include atenolol, bisoprolol, metoprolol, nadolol, propranolol.
- Examples of nondihydropyridine calcium channel blockers cited include diltiazem and verapamil.
Required clinical documentation and timing
Include clinical documentation demonstrating diagnosis, symptom class, pre‑treatment cardiac measurements, prior therapy attempts, and (for reauthorization) clinical response.
- Diagnosis: obstructive hypertrophic cardiomyopathy (HCM).
- NYHA class: II or III.
- Pre‑treatment measurements obtained prior to starting therapy: LVEF (initial ≥55%; reauthorization ≥50%) and LVOT peak gradient (≥50 mmHg at rest or with provocation).
- Documentation of inadequate response/intolerance/failure/contraindication to one non‑vasodilating beta blocker or one nondihydropyridine calcium channel blocker at maximally tolerated dose.
- For reauthorization: evidence of positive clinical response (e.g., reduction in NYHA class or no worsening).
Triggers for denial
Requests will be denied if required diagnosis, symptom class, pre‑treatment measurements, prior therapy trial, or combination‑therapy exclusions are not met.
- No diagnosis of obstructive HCM.
- NYHA class is not II or III.
- Pre‑treatment LVEF and/or LVOT peak gradient not documented (initial LVEF ≥55%; LVOT ≥50 mmHg).
- No documentation of trial (or intolerance/failure/contraindication) of one non‑vasodilating beta blocker or one nondihydropyridine calcium channel blocker at maximally tolerated dose.
- Concurrent use of another cardiac myosin inhibitor (e.g., Myqorzo/aficamten).
Background
Mavacamten (Camzyos) is a cardiac myosin inhibitor indicated to improve functional capacity and symptoms in adults with symptomatic obstructive hypertrophic cardiomyopathy (HCM) classified as NYHA class II–III. Prior to initiating therapy, patients must have documented pre-treatment measurements including LVEF ≥55% and an LVOT peak gradient ≥50 mmHg at rest or with provocation; treatment should be prescribed by or in consultation with a cardiologist. Authorizations are issued for 12 months, and ongoing therapy requires documentation of clinical benefit and maintenance of adequate LVEF (≥50% on reauthorization).
Definitions
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