CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Verquvo (vericiguat) coverage

Policy governs coverage and authorization criteria for vericiguat (Verquvo) for adults with symptomatic chronic heart failure with reduced ejection fraction under Neighborhood Health Plan of Rhode Island Medicaid.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVerquvo (vericiguat) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateApr 1, 2025

Key ActionObtain prior authorization with documentation of NYHA class, LVEF <45%, age ≥18, cardiology prescriber or consult, optimized HF therapy, and recent HF hospitalization or outpatient IV diuretics if initiating.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

LVEF <45%LVEF requirement

NYHA II-IVFunctional class

10 mg/dayMax daily dose

1 tablet/dayDosing limits

1 yearAuth duration

Coverage Criteria for Verquvo (vericiguat)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVerquvo (vericiguat) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateApr 1, 2025

SourceLink

On This Page

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Initial approval criteria

Covered when ALL of the following are met:

Age: Patient is at least 18 years of age>=18 years

Diagnosis and severity: Symptomatic chronic heart failure NYHA class II-IVNYHA II-IV

Ejection fraction: Left ventricular ejection fraction less than 45 percentLVEF <45%

Documentation of LVEF required

Prescriber: Medication is being prescribed by or in consultation with a cardiologist

Dose limit: Requested dose does not exceed 10 mg/day<=10 mg/day

Maximum 1 tablet/day

Background therapy: Patient is currently receiving optimal therapy for heart failure management (e.g., ACEI, ARB, ARNI, beta-blocker)on guideline-directed HF therapy

Recent HF event for initiation: If not continuation of therapy, patient has EITHER: A) hospitalization for heart failure within the past 6 months OR B) use of outpatient IV diuretics for heart failure within the past 3 monthshospitalization within 6 months OR outpatient IV diuretics within 3 months

Applies only to initiation requests

All indications for vericiguat (Verquvo) other than the FDA-approved indication described below are considered experimental/investigational and are not a covered benefit.

Use of vericiguat for non–FDA-approved indications or when the stated approval criteria are not met is considered not medically necessary/not covered. Prior authorization is required for the FDA‑approved indication; requests that do not document the required clinical criteria (including age, NYHA class, left ventricular ejection fraction <45%, cardiology involvement, background guideline-directed heart failure therapy, or recent HF hospitalization/outpatient IV diuretic use when initiating therapy) are subject to denial.

Prior Authorization, Documentation, and Prescriber Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Approvals are limited to 1 year and dosing/quantity limits apply (maximum 10 mg/day; 1 tablet/day).

Prior authorization required
Approval duration: 1 year
Dose/quantity limit: 1 tablet/day; ≤10 mg/day

Documentation Required

Indication Must Be FDA‑Approved

The indication must be FDA‑approved. Verquvo is FDA‑approved to reduce the risk of cardiovascular death and heart failure hospitalization following a hospitalization for heart failure or need for outpatient IV diuretics, in adults with symptomatic chronic HF and ejection fraction <45%. Requests for indications outside this FDA‑approved indication are considered experimental/investigational and are not covered.

Denial Risk

Failure to Meet Approval Criteria / Denial Risk

Providers must document that all approval criteria are met. Common reasons for denial include missing or not meeting any of the required criteria: age <18, NYHA class outside II–IV, LVEF ≥45%, dose >10 mg/day, patient not on guideline‑directed background HF therapy, lack of cardiology involvement (prescriber not cardiologist or no cardiology consult), or absence of a qualifying recent HF event (HF hospitalization within 6 months or outpatient IV diuretics within 3 months) when initiating therapy.

Age ≥18 required
NYHA class II–IV required
LVEF <45% required
Dose must not exceed 10 mg/day
Patient must be on optimal background HF therapy (ACEI/ARB/ARNI, beta‑blocker, etc.)
Medication prescribed by or in consultation with a cardiologist
For new starts: qualifying HF event — hospitalization for HF within 6 months OR outpatient IV diuretics within 3 months

Background on Vericiguat

Vericiguat (brand name: Verquvo) is an oral soluble guanylate cyclase stimulator indicated to reduce the risk of cardiovascular death and heart failure hospitalization in adults with symptomatic chronic heart failure and reduced ejection fraction. The FDA-approved indication specifies use following a hospitalization for heart failure or the need for outpatient intravenous diuretics in patients with left ventricular ejection fraction <45%, as an adjunct to optimal guideline-directed medical therapy and with cardiology involvement.

Definitions & Initiation Timing

FDA-approved indication

FDA‑approved indicationReduce the risk of cardiovascular death and heart failure hospitalization following a hospitalization for heart failure or need for outpatient IV diuretics, in adults with symptomatic chronic heart failure and ejection fraction less than 45%.

PopulationAdults with symptomatic chronic heart failure (NYHA class II‑IV)

LimitationAll other indications are considered experimental/investigational and are not covered.

Initiation criteria time windows

Initiation criteria — hospitalization windowHospitalization for heart failure within the past 6 months

Initiation criteria — outpatient IV diuretics windowUse of outpatient IV diuretics for heart failure within the past 3 months

ApplicabilityRequirement applies only to initiation (not continuation) requests; one of the two events must be documented

OpenPayer

Verquvo (vericiguat) coverage

Coverage Criteria for Verquvo (vericiguat)

Key Clinical Thresholds & Dosing

Prior Authorization, Documentation, and Prescriber Requirements

Background on Vericiguat

Definitions & Initiation Timing