CurrentColorado Rocky Mountain Health PlansPolicy 2026 P 2281-6

Camzyos® (mavacamten) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plansopen_in_new

Defines prior authorization and medical necessity criteria for Camzyos (mavacamten) for adults with symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy, including initial and reauthorization requirements, prescribing provider scope, and program operational notes for UnitedHealthcare Commercial Plans. Effective date listed in header: 2026-05-01.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCamzyos® (mavacamten) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plansopen_in_new

Policy CodePolicy 2026 P 2281-6

Change TypeCriteria revised (LVEF/LVOT) + step therapy update

Effective DateMay 1, 2026

Next Review Date

Key ActionCamzyos requires prior authorization and will be approved only if the initial or reauthorization clinical criteria are met; authorization will be issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

Updated criteria for LVEF and LVOT measurements; added restriction against combination with another cardiac myosin inhibitor (2/2026).

Revised step therapy requirement to include either one non-vasodilating beta blocker or one nondihydropyridine calcium channel blocker (8/2025).

Program established and initial approvals defined (7/2022 onward).

2NYHA classes covered

55% / 50%LVEF thresholds (initial / reauth)

Coverage Summary

Coverage stance: covered_with_criteria. Policy number: 2026 P 2281-6. Payer program effective date: 2026-05-01. Status: CURRENT. Scope: Defines prior authorization and medical necessity criteria for Camzyos (mavacamten) for adults with symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy. Indication summary: Camzyos is indicated for adults with symptomatic NYHA class II-III obstructive HCM to improve functional capacity and symptoms. Prior authorization is required and will be approved only if the initial or reauthorization clinical criteria are met. Authorization duration: 12 months.

Initial Therapy Criteria

Continuation / Reauthorization Criteria

Provider Actions & Operational Rules

Prior Authorization

Prior authorization required

Camzyos requires prior authorization and will be approved only if the initial or reauthorization clinical criteria are met; authorization will be issued for 12 months.

Documentation Required

Baseline measurements required

Provide documentation of baseline left ventricular ejection fraction (LVEF) greater than or equal to 55% and Valsalva left ventricular outflow tract (LVOT) peak gradient greater than or equal to 50 mmHg at rest or with provocation measured prior to Camzyos therapy.

Documentation Required

Prior trial of therapy requirement

Document inadequate response, intolerance, failure, or contraindication to one non-vasodilating beta blocker or one nondihydropyridine calcium channel blocker at a maximally tolerated dose for initial approval.

Documentation Required

Reauthorization response documentation

For reauthorization, provide documentation of positive clinical response to therapy (for example, reduction in NYHA class or no worsening in NYHA class) and a left ventricular ejection fraction (LVEF) greater than or equal to 50%.

Documentation Required

Prescriber specialty

Camzyos must be prescribed by or in consultation with a cardiologist; include documentation of cardiology involvement with the prescription.

Denial Risk

Contraindicated combination

Claims may be denied if Camzyos is used in combination with another cardiac myosin inhibitor (for example, Myqorzo/aficamten).

Billing Rule

Authorization duration

Approved authorizations are issued for 12 months.

Applicable Codes

ICD-10 Diagnosis codes (referenced generically)ICD-10

No codes listed

Clinical Evidence & References

Evidence references: Camzyos® [package insert], Bristol Myers Squibb; April 2025; Mavacamten for Hypertrophic Cardiomyopathy: Final Evidence Report, ICER, Nov 16, 2021; and the 2024 AHA/ACC guideline for management of hypertrophic cardiomyopathy. Note: Criteria in this policy align with product labeling and guideline/evidence references as stated in the background.

Background & Definitions

Background: Camzyos (mavacamten) is a cardiac myosin inhibitor indicated for the treatment of adults with symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy to improve functional capacity and symptoms. The policy outlines clinical criteria for prior authorization and reauthorization, including baseline measurements (LVEF and Valsalva LVOT peak gradient), step therapy and prescriber requirements, and is aligned with the product labeling and guideline/evidence references.

Term	Definition
NYHA class II-III	New York Heart Association functional classification indicating symptomatic heart failure limiting ordinary activity (class II) or marked limitation of activity (class III).
LVOT peak gradient	Left ventricular outflow tract peak pressure gradient measured at rest or with provocation (Valsalva) expressed in mmHg.

Revision History

2/2026material_changeLatest

Updated criteria to clarify LVEF and Valsalva LVOT peak gradient measurements must be performed prior to initiation of Camzyos therapy; added explicit 'not used in combination' restriction (e.g., Myqorzo/aficamten).

8/2025material_change

Revised step therapy requirement to simplify prior trial: require history of inadequate response, intolerance, failure, or contraindication to either one non-vasodilating beta blocker or one nondihydropyridine calcium channel blocker; simplified documentation criteria for positive clinical response on reauthorization.

7/2022program_creation