CurrentUnitedHealthcarePolicy N/A

Mavacamten (Camzyos) prior authorization checklist for obstructive hypertrophic cardiomyopathy

Criteria and checklist for initial and continuation authorization of mavacamten (Camzyos) for adults with obstructive hypertrophic cardiomyopathy, including monitoring and contraindicated concomitant medications; applies to UnitedHealthcare reviewers and prescribing clinicians.

Policy Summary

PayerUnitedHealthcare

PolicyMavacamten (Camzyos) prior authorization checklist for obstructive hypertrophic cardiomyopathy

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization checklist documenting age ≥18, obstructive HCM diagnosis, NYHA II–III, required LVEF threshold, monitoring plan, and prior beta-blocker trial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13checklist items

18+min age

≥55%initiation LVEF

≥50%continuation LVEF

NYHA II–IIIsymptom class

Coverage Criteria for Mavacamten (Camzyos)

Initial Therapy

Covered when ALL of the following are met

Initial authorization criteria: 1) Beneficiary age ≥ 18 years; 2) Diagnosis of obstructive hypertrophic cardiomyopathy (oHCM) consistent with current guidelines (e.g., ACC/AHA, ESC); 3) NYHA Class II or III symptoms; 4) Monitoring plan in place for LVEF, Valsalva LVOT assessment, and heart failure symptoms (e.g., dyspnea, chest pain, arrhythmia, palpitations, fatigue, peripheral edema); 5) Adequate echocardiogram or cardiovascular magnetic resonance imaging (CMR) available for baseline assessment; 6) Plan to avoid concomitant use with moderate to strong CYP2C19 inhibitors, strong CYP3A4 inhibitors, and moderate to strong CYP2C19 and CYP3A4 inducers (examples: carbamazepine, cimetidine, esomeprazole, omeprazole, phenobarbital, phenytoin, rifampin, St. John's wort); 7) For females of childbearing potential, a pregnancy test confirming the beneficiary is not pregnant; 8) Mavacamten prescribed by or in consultation with a cardiologist; 9) Adequate trial and failure of ≥ 1 beta-blocker; 10) Documented left ventricular ejection fraction (LVEF) ≥ 55% (initiation only)

All items listed on the initial checklist must be documented

Continuation Therapy

Continued coverage requires ALL of the following

Policy Summary

PayerUnitedHealthcare

PolicyMavacamten (Camzyos) prior authorization checklist for obstructive hypertrophic cardiomyopathy

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization checklist documenting age ≥18, obstructive HCM diagnosis, NYHA II–III, required LVEF threshold, monitoring plan, and prior beta-blocker trial.

SourceLink

On This Page

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Use of mavacamten is not supported when the patient fails to meet any required initiation or continuation checklist item. Examples explicitly called out on the form include: patient age <18 years; diagnosis not consistent with obstructive hypertrophic cardiomyopathy per current guidelines; NYHA class outside II–III; inadequate imaging or monitoring for LVEF and LVOT assessment; lack of required trial and failure of ≥1 beta-blocker for initiation; and LVEF below the required thresholds for initiation (LVEF < 55% for initiation) or continuation (LVEF < 50% for continuation). The form also notes that continuation is not supported if there is no evidence of disease improvement/stabilization or if the beneficiary has treatment-restricting adverse effects (for example, heart failure).

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Mavacamten (Camzyos). Complete the checklist on the PA form and provide required monitoring plans before initiation.

Prescriber: cardiologist or in consultation with a cardiologist.
Provide echocardiogram or CMR documentation for baseline LVEF and LVOT assessment.
Monitoring plan must include serial LVEF assessment, LVOT/Valsalva assessment, and surveillance for heart failure symptoms.

Denial Risk

Denial Risk — Enrollment Thresholds

Denial risk if the patient does not meet enrollment thresholds. Requests lacking required age, diagnosis, NYHA class, or LVEF will be denied.

Age: beneficiary must be ≥ 18 years at initiation.
Diagnosis: obstructive hypertrophic cardiomyopathy (oHCM) consistent with current guideline criteria.
NYHA: symptoms consistent with NYHA Class II or III.
LVEF: documented LVEF ≥ 55% for initiation (continuation requires LVEF ≥ 50%).

Documentation Required

Documentation must be submitted with the request and retained in the medical record.

Diagnosis documentation consistent with current ACC/AHA or ESC oHCM guidelines.
Baseline and follow-up LVEF values with dates (echocardiogram or CMR).
Baseline and follow-up LVOT assessment (including Valsalva maneuver when available).
Evidence of adequate baseline imaging (echocardiogram or CMR reports).

Step Therapy

Initial Therapy — Prior Trial Requirement

Initial therapy expectations before approval.

Prior trial and inadequate response or intolerance to ≥ 1 beta‑blocker must be documented (drug name, dose, duration, and reason for failure).
For females of childbearing potential: negative pregnancy test prior to initiation and counseling on contraception.
Plan to avoid concomitant use with moderate–strong CYP2C19 inhibitors, strong CYP3A4 inhibitors, and relevant inducers must be documented.

Background

This checklist governs prior authorization of mavacamten for adults with obstructive hypertrophic cardiomyopathy (oHCM). It focuses on symptomatic adult patients with NYHA Class II–III, requires documentation of diagnosis consistent with current cardiology guidelines, baseline and follow-up assessment of left ventricular ejection fraction and Valsalva left ventricular outflow tract (LVOT) dynamics by adequate echocardiogram or CMR, and a monitoring plan for heart failure symptoms. The checklist also mandates cardiology prescribing or consultation, a required trial and failure of at least one beta-blocker for initiation, and avoidance of interacting CYP2C19/CYP3A4 drugs; specific LVEF thresholds are specified for initiation (≥ 55%) and continuation (≥ 50%).

OpenPayer

Mavacamten (Camzyos) prior authorization checklist for obstructive hypertrophic cardiomyopathy

Coverage Criteria for Mavacamten (Camzyos)

Key Clinical Thresholds and Coding Notes

Provider Actions and Prior Authorization Requirements

Background

Definitions