Camzyos (mavacamten) prior authorization for obstructive hypertrophic cardiomyopathy
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Defines prior authorization criteria, duration, and administrative processes for Camzyos (mavacamten) for Georgia Medicaid Fee-for-Service members with obstructive hypertrophic cardiomyopathy. Applies to prescribers, pharmacies, and members seeking coverage under Georgia Medicaid FFS.
No material clinical or coverage changes in this revision.
Camzyos (mavacamten) Coverage Criteria
To request a coverage exception, providers should initiate the prior authorization process with OptumRx. Exceptions to the stated coverage conditions are evaluated through the PA process; to begin an exception request call OptumRx at 1-866-525-5827. Prior authorization is the mechanism by which exceptions are reviewed and adjudicated.
Drug and Clinical Thresholds
| mavacamten | Camzyos (mavacamten) — referenced medication name |
Prior Authorization and Documentation Requirements
Prior authorization and REMS enrollment required for Camzyos
Camzyos (mavacamten) requires prior authorization and will be approved only when all specified clinical criteria are met and the prescriber, member and pharmacy are enrolled in the Camzyos REMS Program; exceptions may be requested through OptumRx.
- Prior authorization is required for coverage.
- REMS enrollment for prescriber, member, and pharmacy is mandatory for approval.
- Exceptions to coverage can be requested via OptumRx.
Required prior medication trials
Before approval, the member must have tried and had inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects to at least one agent from each specified medication class at maximally tolerated doses.
- Non-vasodilating beta blocker (e.g., bisoprolol, propranolol, metoprolol, labetalol, pindolol, atenolol) — trial required.
- Non-dihydropyridine calcium channel blocker (diltiazem or verapamil) — trial required.
- Disopyramide — trial required.
Required documentation to support PA
Submit documentation with the prior authorization request demonstrating diagnosis and clinical measures, prior medication trials or intolerances, REMS enrollment, and cardiology involvement.
- Imaging confirmation of LVH (echocardiography or cardiac MRI) and statement that LVH is not due to a systemic disorder or secondary cause.
- Left ventricular ejection fraction (LVEF) ≥ 55%.
- Valsalva LVOT peak gradient ≥ 50 mmHg at rest or with provocation.
- NYHA functional class II–III documentation.
- Records showing trials and inadequate response/intolerance to required medication classes at maximally tolerated doses.
- Evidence of prescriber or consult with a cardiologist and enrollment in the Camzyos REMS Program.
Denial triggers for Camzyos prior authorization
A prior authorization request for Camzyos may be denied if any of the approval criteria are not met.
- Member is under 18 years of age.
- Diagnosis is not obstructive HCM confirmed by imaging or LVH is attributable to a secondary cause.
- NYHA class is not II–III.
- LVEF is less than 55%.
- Valsalva LVOT peak gradient is less than 50 mmHg at rest or with provocation.
- No documented trials or documented intolerance/allergy/contraindication to required medication classes at maximally tolerated doses.
- Prescriber, member or pharmacy are not enrolled in the Camzyos REMS Program.
- Medication not prescribed by or in consultation with a cardiologist.
Clinical Background
Obstructive hypertrophic cardiomyopathy (HCM) is a condition marked by left ventricular hypertrophy (LVH) not caused by secondary systemic disorders, which can produce symptomatic left ventricular outflow tract (LVOT) obstruction. Management typically begins with medical therapy—non-vasodilating beta blockers, non-dihydropyridine calcium channel blockers, and disopyramide—before considering septal reduction procedures or targeted agents such as mavacamten (Camzyos). Treatment candidacy for mavacamten requires imaging confirmation of LVH and demonstration of symptomatic obstruction, along with other specified clinical criteria.
Key Definitions and Program Requirements
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