CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Camzyos (mavacamten) — coverage criteria for obstructive hypertrophic cardiomyopathy

Covers use of Camzyos for adults with symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy (oHCM) under Medicaid when specified approval criteria are met.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCamzyos (mavacamten) — coverage criteria for obstructive hypertrophic cardiomyopathy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization for 6 months only when all initiation criteria are met, including cardiologist prescriber enrolled in CAMZYOS REMS and required documentation (age ≥18, weight ≥45 kg, NYHA II–III, LV wall thickness and LVOT gradient, LVEF ≥55%).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 moinitial authorization duration

6 mocontinuation authorization duration

1 cap/dayquantity limit

≥18minimum age

>50%continuation LVEF requirement

Coverage Criteria for Camzyos (mavacamten)

Initial Therapy — authorization of 6 months may be granted when ALL of the following are met

Authorization of 6 months may be granted when ALL of the following are met

Initiation Criteria: Member is an adult (>=18 years) and weight >=45 kg; prescriber is a cardiologist enrolled in the CAMZYOS REMS PROGRAM; symptomatic obstructive hypertrophic cardiomyopathy (NYHA class II-III); documented left ventricular wall thickness >=15 mm (or >=13 mm with a pathogenic sarcomeric gene variant as specified in the record); baseline Valsalva LVOT peak gradient >=50 mm Hg; documented LVEF >=55%; documentation of inadequate response, intolerance, or contraindication to beta blockers (e.g., metoprolol, propranolol, atenolol), nondihydropyridine calcium channel blockers (verapamil, diltiazem), and disopyramide when applicable; member is not currently treated with or planning treatment with disopyramide, ranolazine, or dual beta blocker plus calcium channel blocker therapy; member is not diagnosed with alternative causes of left ventricular hypertrophy that mimic oHCM (e.g., Fabry disease, amyloidosis, Noonan syndrome with LV hypertrophy).

Continuation Therapy — authorization of 6 months may be granted for continued treatment when ALL of the following are met

Authorization of 6 months may be granted for continued treatment when ALL of the following are met

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCamzyos (mavacamten) — coverage criteria for obstructive hypertrophic cardiomyopathy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2022

Next Review DateN/A

SourceLink

On This Page

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Clinical Parameters and Coding-related Thresholds

Baseline Valsalva LVOT peak gradient

Baseline Valsalva LVOT peak gradient>= 50 mm Hg

Measurement contextDocumented baseline Valsalva LVOT peak gradient used for initiation criteria

Authorization linkageRequired for initial 6-month prior authorization for oHCM

Left ventricular wall thickness

Left ventricular wall thickness (standard)>= 15 mm anywhere in the left ventricle

Genetic exception>= 13 mm if pathogenic sarcomeric gene variant present (e.g., MYBPC3, TNNI3, TNNT2, TPM1, MYL2, MYL3, ACTC1)

Documentation requirementEchocardiographic or imaging report documenting maximal wall thickness is required

Minimum weight requirement

Minimum weight>= 45 kg

DocumentationMember weight must be recorded in clinical documentation for initiation

RelevancePart of the eligibility criteria for initial 6-month authorization

Left ventricular ejection fraction — initiation and continuation thresholds

Initiation LVEF thresholdDocumented LVEF >= 55% required for treatment initiation

Continuation LVEF thresholdLVEF > 50% required to continue therapy

DocumentationLVEF must be included in records for both initiation and continuation reviews

Minimum age requirement

Minimum age>= 18 years

ScopePolicy coverage limited to adults with symptomatic NYHA class II-III oHCM

DocumentationMember age must be documented for prior authorization

Prior Authorization, Documentation, and Prescriber Requirements

Prior Authorization

Prior Authorization Required

Authorization of 6 months may be granted for treatment of obstructive hypertrophic cardiomyopathy (oHCM) when initiation criteria are met. Prior authorization is required before starting therapy.

Authorization period: up to 6 months when initiation criteria met

Step Therapy

Step Therapy Requirements

Step therapy applies: prior inadequate response, intolerance, or contraindication to standard therapies must be documented before approval.

Required step therapies may include beta blockers, nondihydropyridine calcium channel blockers (verapamil, diltiazem), and/or disopyramide as appropriate

Documentation Required

Required Clinical Documentation

Clinical documentation must be provided with the prior authorization request to support medical necessity for oHCM therapy.

Patient age (≥ 18 years) and weight (≥ 45 kg)
Documentation of symptomatic obstructive HCM meeting FDA indication (NYHA Class II–III)
Left ventricular ejection fraction (LVEF) ≥ 50%
Baseline Valsalva left ventricular outflow tract (LVOT) peak gradient ≥ 50 mm Hg
Left ventricular wall thickness (e.g., ≥ 15 mm, or ≥ 13 mm with pathogenic sarcomeric gene variant)
Documentation of inadequate response, intolerance, or contraindication to beta blockers
Documentation of inadequate response, intolerance, or contraindication to nondihydropyridine calcium channel blockers (verapamil, diltiazem)
Documentation of inadequate response, intolerance, or contraindication to disopyramide when applicable
Document that patient is not currently treated with disopyramide, ranolazine, or dual beta blocker + calcium channel blocker therapy
Documentation that the member does not have another disorder that causes cardiac hypertrophy that mimics oHCM (e.g., Fabry disease, amyloidosis, Noonan syndrome with LV hypertrophy)

Documentation Required

Prescriber and REMS

This medication must be prescribed by a cardiologist who is enrolled in the CAMZYOS REMS Program. Prescribers must ensure REMS enrollment prior to prescribing and include evidence of REMS enrollment in the authorization request.

Prescriber requirement: cardiologist enrolled in CAMZYOS REMS PROGRAM
Include REMS enrollment confirmation with prior authorization submission

Denial Risk

Indication Restrictions

Use of this drug for indications other than FDA‑approved symptomatic oHCM (NYHA Class II–III) is considered experimental/investigational and not medically necessary.

Non‑FDA indications are not covered

OpenPayer

Camzyos (mavacamten) — coverage criteria for obstructive hypertrophic cardiomyopathy

Coverage Criteria for Camzyos (mavacamten)

Clinical Parameters and Coding-related Thresholds

Prior Authorization, Documentation, and Prescriber Requirements

Background on Camzyos (mavacamten)

Key Definitions