CurrentMass General Brigham Health PlanPolicy N/A

Verquvo (vericiguat) — Pharmacy prior authorization and step therapy

This policy governs pharmacy benefit prior authorization and step-therapy rules for Verquvo (vericiguat) for Mass General Brigham Health Plan commercial/exchange members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyVerquvo (vericiguat) — Pharmacy prior authorization and step therapy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review Date

Key ActionSubmit a prior authorization request for members who do not meet initial step therapy requirements and include documentation of prior use or inadequate response/intolerance to first-line therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercial/Exchangeapplicable plan

Prior Authorizationprogram type

24 monthsapproval duration

1 tablet/dayquantity limit

Coverage Criteria for Verquvo (vericiguat)

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Initial Coverage Criteria for Verquvo

Covered when ALL of the following are met

Step therapy requirements: Member has filled a first-line medication (e.g., Entresto) or a second-line medication within the past 180 days, OR has documented inadequate response, side effect, or allergy to a first-line medication.filled within past 180 days

Entresto (sacubitril/valsartan) is considered first-line; Verquvo (vericiguat) is considered second-line.

Prior Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Verquvo when the prescription does not meet the initial step-therapy requirements. Entresto (sacubitril/valsartan) is identified in the policy as a first-line agent; Verquvo is designated as a second-line agent and will require PA when step therapy is not met.

Verquvo (vericiguat) — PA required when step therapy not met
Entresto (sacubitril/valsartan) — listed as first-line

Step Therapy

Initial Step‑Therapy Requirements

Initial step-therapy: First-line medications are covered with prior authorization. Second-line medications (including Verquvo) will adjudicate only if the member has filled a first-line medication or a second-line medication within the past 180 days.

First-Line: covered with prior authorization
Second-Line: member must have a fill for a first-line or second-line medication within the past 180 days

Documentation Required

PA Submission and Supporting Documentation

Submit a prior authorization request when a prescription denies at point of sale for not meeting initial step therapy requirements. Include documentation demonstrating prior use of a first-line medication or clinical rationale (inadequate response, adverse reaction, or allergy) supporting use of a second-line agent.

Include prior fill history showing a first-line or second-line medication within the past 180 days, or clinical documentation of inadequate response/side effects/allergy to a first-line agent
If step therapy not met, the claim will deny at POS with message indicating PA is required

Denial Risk

PA Required When Step Therapy Not Met

Prescriptions that do not meet the initial step-therapy requirements will deny at the point of sale with a message indicating prior authorization is required. Providers should submit PA requests promptly with the required supporting documentation to avoid delays in therapy.

Denial at POS when step therapy unmet — PA message will display
Timely PA submission with documentation may allow approval of second-line therapy

Background

Verquvo (vericiguat) is positioned as a second-line therapy in this plan’s formulary. Entresto (sacubitril/valsartan) is treated as a first-line medication and prior use of a first-line agent is required before Verquvo will be approved under the step-therapy rules unless there is documented intolerance or inadequate response. Second-line agents such as Verquvo will pay without a prior authorization only when the member has filled a first-line medication or a second-line medication within the past 180 days.

If the member does not meet the initial step-therapy requirements, approval of Verquvo may be granted when there is documentation of an inadequate response, side effect, or allergy to a first-line medication; otherwise a prior authorization is required for coverage.

Definitions

Definition of Second-Line

Definition — Second-LineA medication that will be covered if the member has filled a first-line medication or a second-line medication within the past 180 days, or if there is documented inadequate response, side effect, or allergy to a first-line medication.

First-line exampleEntresto (sacubitril/valsartan)

When PA is requiredIf step therapy conditions are not met, prior authorization is required with documentation of inadequate response/intolerance to first-line therapy.

Initial Therapy Positioning

Initial step-therapy positioning

First-line requirement: First-line medications are covered with prior-authorization; members should use first-line therapy (Entresto) prior to Verquvo unless there is documented intolerance or inadequate response.N/A

Second-line (Verquvo) pays if first-line used within 180 days or documented intolerance/inadequate response.

Step Therapy Requirements

Step	Requirement	Lookback / Documentation	Coverage Status
1	Member must have filled a first-line medication (e.g., Entresto [sacubitril/valsartan]) or a second-line medication	Fill within the past 180 days	Pays without additional PA when lookback met
2	If lookback not met, documented inadequate response, side effect, or allergy to a first-line medication is required for approval	Submit documentation of inadequate response, adverse reaction, or allergy to first-line therapy	Requires prior authorization