CurrentColorado Rocky Mountain Health PlansPolicy N/A

Verquvo (vericiguat) prior authorization

Defines prior authorization and reauthorization criteria for Verquvo (vericiguat) for adults with symptomatic chronic heart failure and reduced ejection fraction; applies to medications managed under the payer's clinical pharmacy programs.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyVerquvo (vericiguat) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 15, 2026

Next Review DateNov 1, 2025

Key ActionObtain prior authorization by documenting symptomatic HF with EF <45%, NYHA II–IV, and a recent qualifying HF event; approvals issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauth duration

<45%EF threshold

II-IVNYHA class

6m / 3mHF look-back

boxed warningcontraindication

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Initial Authorization

Covered when ALL of the following are met:

ALL of the following

Diagnosis of symptomatic heart failure
Ejection fraction < 45%< 45%
Heart failure classified as NYHA Class II, III, or IV
Select the appropriate NYHA class documentation
One of the following must be present:
- Hospitalization for heart failure within the past 6 months<= 6 months
- Outpatient IV diuretics for heart failure within the past 3 months<= 3 months

Reauthorization

Covered when the following is met:

ALL of the following

Documentation of a positive clinical response to Verquvo (vericiguat) therapy

Use during pregnancy is contraindicated due to embryo-fetal toxicity (boxed warning). Authorization will be issued for 12 months. State mandates may apply. Any federal regulatory requirements and the member specific benefit plan coverage may also impact coverage criteria. Other policies and utilization management programs may apply.

Initial Therapy

Initial therapy

Initial approval conditions

Initial Therapy: Patient has symptomatic heart failure; ejection fraction <45%; NYHA Class II, III, or IV; and either hospitalization for heart failure within the past 6 months OR outpatient IV diuretics for heart failure within the past 3 months.< 45% ejection fraction

Approval duration: 12 months

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required for Verquvo. Initial approval is granted when all specified clinical criteria are met: symptomatic heart failure, ejection fraction <45%, NYHA class II–IV, and either a heart-failure hospitalization within the past 6 months or outpatient IV diuretics for heart failure within the past 3 months. Authorization duration: 12 months.

Initial approval requires ALL listed criteria (symptomatic HF; EF <45%; NYHA II–IV; recent HF hospitalization within 6 months OR outpatient IV diuretics within 3 months).
Authorization period: 12 months.

Note

Automated Approval Note

Automated approval and re-approval processes may be used based on prior claim/medication history, diagnosis codes (ICD-10), and other claim-logic per program rules. Use of automation varies by program and therapeutic class.

Approvals may be granted based solely on previous claims/medication history and diagnosis codes.
Program-level logic determines when automated processes apply.

Documentation Required

Reauthorization Documentation

For reauthorization, documentation demonstrating a positive clinical response to Verquvo therapy is required. Ensure clinical notes or objective measures supporting improvement or stabilization of heart-failure signs/symptoms are included.

Required: clinical documentation of positive response to therapy for reauthorization.

Denial Risk

Denial Triggers for Initial Authorization

Initial authorization will be denied if all required initial criteria are not met. Common denial triggers include: absence of symptomatic heart failure; ejection fraction ≥45%; NYHA class outside II–IV; or lack of recent qualifying HF event (no HF hospitalization within 6 months and no outpatient IV diuretics within 3 months).

Denial triggers: missing any of the required initial criteria (symptomatic HF; EF <45%; NYHA II–IV; recent HF hospitalization within 6 months OR outpatient IV diuretics within 3 months).

Definitions Used in This Policy

inv-10: Symptomatic chronic heart failure (policy)

DefinitionSymptomatic chronic heart failure: heart failure presenting with symptoms and an ejection fraction less than 45% (per policy eligibility).

Indication contextVerquvo indicated to reduce risk of CV death and HF hospitalization in adults with symptomatic chronic HF and EF <45% after HF hospitalization or need for outpatient IV diuretics.

Related requirementNYHA Class II–IV required for initial authorization

inv-11: Positive clinical response

DefinitionPositive clinical response: documented clinical improvement while on Verquvo as required for reauthorization.

Reauthorization requirementDocumentation of positive clinical response required for reauthorization; approvals issued for 12 months.

Action for providersSubmit clinical notes documenting improvement during Verquvo therapy at time of reauthorization request.

Step	Requirement / Note
1	Program may use automated approvals and re-approvals based on prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic; specific step edits are not defined.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyVerquvo (vericiguat) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 15, 2026

Next Review DateNov 1, 2025

Key ActionObtain prior authorization by documenting symptomatic HF with EF <45%, NYHA II–IV, and a recent qualifying HF event; approvals issued for 12 months.

SourceLink

On This Page

OpenPayer

Verquvo (vericiguat) prior authorization

Coverage Criteria for Verquvo (vericiguat)

Initial Therapy

Continuation / Reauthorization Criteria

Provider Actions and Prior Authorization

Key Clinical Thresholds and Coding

Definitions Used in This Policy

Background

Step Therapy / Program Logic