CurrentMass General Brigham Health PlanPolicy N/A

Verquvo (vericiguat) prior authorization and step therapy

This document governs prior authorization, step therapy, and quantity limits for vericiguat (Verquvo) under Mass General Brigham Health Plan pharmacy benefits, affecting prescribers and pharmacists managing member prescriptions.

Policy Summary

PayerMass General Brigham Health Plan

PolicyVerquvo (vericiguat) prior authorization and step therapy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionSubmit a prior authorization request for members who do not meet initial step therapy requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 moapproval duration

180 dayslookback period

1/dayquantity limit

Entrestorequired prior

Coverage Criteria for Verquvo (vericiguat)

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Second-line criteria: 1) Verquvo (vericiguat) is requested as a second-line medication; AND 2) The member has filled a first-line medication (e.g., Entresto/sacubitril-valsartan) or a second-line medication within the past 180 days; OR 3) There is documented inadequate response, unacceptable side effect, or allergy to a first-line medication.lookback 180 days

Entresto is listed as first-line and prior authorization is required for first-line agents.

Duration and Quantity Limits

Approval limits: Approvals will be granted for 24 months; quantity limits apply as listed (example: 1 tablet per day for listed tablet strengths).24 months

Quantity limit language in source lists 1 tablet per day across specified tablet strengths.

No additional exclusions are listed beyond the plan's step therapy designation. Entresto (sacubitril/valsartan) is required as the first-line agent; Verquvo (vericiguat) is designated as a second-line medication. Approval for Verquvo is only granted when the member either has documented inadequate response, side effects, or an allergy to a first-line medication, or otherwise meets the plan's step therapy criteria.

Initial Therapy / Step Therapy Requirements

Initial Therapy / Step Therapy

Initial step-therapy rules

Initial step: First-line medications are covered with prior authorization; Verquvo is designated as a second-line agent and requires prior trial/fill of a first-line medication (Entresto) or a second-line medication within the 180-day lookback period, OR documented inadequate response, side effect, or allergy to a first-line medication.180 days lookback

Prescriptions not meeting these requirements will deny at point of sale.

Continuation / Renewal Criteria

Continuation Therapy

Renewal/continuation rules

Continuation approval: Approvals for Verquvo are granted for 24 months; renewals should follow plan procedures and be submitted per the plan’s prior authorization/renewal process within that interval.24 months

Document lists 24-month approval period.

Step Therapy Details

Requirement	Details	Coverage
Prior trial/fill	Member must have filled a first-line medication (e.g., Entresto [sacubitril/valsartan]) or a second-line medication within the past 180 days	Coverage allowed when met
Documented intolerance or inadequate response	If member has not met the prior-fill requirement, approval may be granted with documentation of an inadequate response, side effect, or allergy to a first-line medication	Coverage allowed when met
Prior authorization	Verquvo is designated second-line; prior authorization is required when initial step therapy requirements are not met	Coverage contingent on PA and meeting criteria

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for Verquvo (vericiguat) when the member does not meet the initial step therapy requirements. Submit a prior authorization request for members who do not meet the initial step therapy requirements at the point of sale.

Affected product: Verquvo (vericiguat)
PA required when initial step therapy not met
Submit PA requests for members denied at point of sale

Step Therapy

Step-Therapy Requirements for Verquvo

Verquvo is designated as second-line therapy. A second-line medication will pay only if the member has filled a first-line medication or a second-line medication within the past 180 days, or there is documentation of an inadequate response, intolerance, or contraindication to a first-line agent.

Second-line = Verquvo (vericiguat)
First-line medications must be filled within the past 180 days to meet step therapy
Approval may be granted with documented inadequate response, side effect/intolerance, or allergy to a first-line agent

Note

PA Submission

Submit a prior authorization request for members who do not meet the initial step therapy requirements. Include documentation of prior medication fills (dates and agents) and any clinical rationale such as inadequate response, adverse effects, or contraindications to first-line therapy.

Include evidence of prior fills (first-line or second-line within 180 days)
Provide clinical documentation for inadequate response, intolerance, or contraindication to first-line therapy

Denial Risk

Point-of-Sale Denial for Unmet Step Therapy

Prescriptions that do not meet the initial step therapy requirements will deny at the point of sale with a message indicating that prior authorization is required. If point-of-sale denial occurs, submit the PA with supporting documentation as described above.

Point-of-sale denial will display message indicating PA required
If denied at POS, submit PA request with required documentation

Definitions

Second-line payment conditions

Coverage conditionSecond-Line medication will pay if the member has filled a first-line medication or a second-line medication within the past 180 days

Alternate approval pathApproval may also be granted if there is documented inadequate response, side effect, or allergy to a first-line medication

First-line exampleEntresto (sacubitril/valsartan) is listed as first-line; Verquvo is designated second-line

First-line coverage

First-line coverageMedications listed on first-line are covered with prior-authorization.

Implication for providersPrescribers should request PA for first-line agents when indicated to ensure coverage

Relation to step therapyFirst-line PA status is part of the initial step-therapy framework determining second-line access

Background

Verquvo (vericiguat) is positioned by the plan as a second-line therapy behind Entresto (sacubitril/valsartan). Entresto requires prior authorization as the first-line agent, and Verquvo authorization is contingent on documented prior use or intolerance/inadequate response to a first-line medication per the step therapy rules.