Myqorzo (aficamten) prior authorization for obstructive hypertrophic cardiomyopathy
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Defines prior authorization and medical necessity criteria for Myqorzo (aficamten) for adults with symptomatic obstructive hypertrophic cardiomyopathy (oHCM) and related reauthorization rules; applies to UnitedHealthcare pharmacy benefits.
No material clinical or coverage changes in this revision.
Coverage Criteria for Myqorzo (aficamten)
Initial Authorization
Covered when ALL of the following are met:
Initial Authorization for Myqorzo
b. Heart failure classification
- (1) New York Heart Association (NYHA) class II heart failure
- (2) New York Heart Association (NYHA) class III heart failure
c. Baseline measurements
- (1) Left ventricular ejection fraction (LVEF) ≥ 55%
- (2) Left ventricular outflow tract (LVOT) peak gradient ≥ 50 mmHg at rest or with provocation (e.g., Valsalva or exercise)
d. Prior therapy trial
- Non-vasodilating beta blocker (e.g., atenolol, bisoprolol, metoprolol, nadolol, propranolol)
- Nondihydropyridine calcium channel blocker (diltiazem or verapamil)
- e. Not used in combination with another cardiac myosin inhibitor (e.g., Camzyos/mavacamten)
- f. Prescribed by or in consultation with a cardiologist
Reauthorization
Reauthorization covered when ALL of the following are met:
Reauthorization for Myqorzo
- b. Left ventricular ejection fraction (LVEF) ≥ 50%
- c. Not used in combination with another cardiac myosin inhibitor (e.g., Camzyos/mavacamten)
- d. Prescribed by or in consultation with a cardiologist
Use of Myqorzo in combination with another cardiac myosin inhibitor is explicitly prohibited. The policy specifies that Myqorzo must not be used together with agents such as Camzyos (mavacamten), and both the initial authorization and reauthorization criteria require absence of concurrent cardiac myosin inhibitor therapy.
Therapy with Myqorzo will be considered not medically necessary and is subject to denial when required baseline measurements or other eligibility conditions are missing. For initial requests, the policy requires documented baseline left ventricular ejection fraction (LVEF) ≥55% and a baseline left ventricular outflow tract (LVOT) peak gradient ≥50 mmHg at rest or with provocation; absence of these measurements may lead to denial. Patients who are not classified as NYHA class II or III do not meet the symptomatic eligibility criteria. Additionally, initial approval requires documentation of a history of inadequate response, intolerance, failure, or contraindication to a maximally tolerated dose of either a non‑vasodilating beta blocker or a nondihydropyridine calcium channel blocker; lack of such prior therapy (or documented intolerance/contraindication) may render treatment not medically necessary. Reauthorization similarly requires documentation of clinical benefit, a current LVEF ≥50%, and continued absence of combination use with another cardiac myosin inhibitor.
Coding and Clinical Thresholds
Provider Requirements and Administrative Actions
Prior authorization and reauthorization required
Prior authorization is required for Myqorzo. Initial approval is granted only when all initial authorization criteria are documented. Reauthorization requires documentation of positive clinical response, LVEF ≥50%, continued absence of combination with another cardiac myosin inhibitor, and cardiologist involvement; authorization is issued for 12 months.
- Initial approval: all criteria in section A.1 (diagnosis of obstructive HCM; NYHA II or III; baseline LVEF ≥55%; baseline LVOT peak gradient ≥50 mmHg at rest or with provocation; prior trial/intolerance of a non-vasodilating beta blocker or nondihydropyridine CCB; not used with another cardiac myosin inhibitor; prescribed by or in consultation with a cardiologist).
- Reauthorization: documentation of positive clinical response (e.g., reduction or no worsening in NYHA class), LVEF ≥50%, not used with another cardiac myosin inhibitor, and prescribed by or in consultation with a cardiologist; approvals issued for 12 months.
Step therapy: trial of specified negative inotropic agents required
A trial (or documented intolerance/failure/contraindication) of one of the specified agents is required before Myqorzo will be approved.
- History of inadequate response, intolerance, failure, or contraindication to one of: a non-vasodilating beta blocker (examples: atenolol, bisoprolol, metoprolol, nadolol, propranolol) OR a nondihydropyridine calcium channel blocker (diltiazem, verapamil).
Required documentation for initial authorization and reauthorization
Document the clinical and baseline measurements required to establish medical necessity prior to initiation and for reauthorization.
- Diagnosis of obstructive hypertrophic cardiomyopathy.
- NYHA functional class II or III.
- Baseline left ventricular ejection fraction (LVEF) ≥55% for initial authorization; LVEF ≥50% for reauthorization.
- Baseline left ventricular outflow tract (LVOT) peak gradient ≥50 mmHg at rest or with provocation (Valsalva or exercise) prior to therapy.
- Documentation of history of inadequate response, intolerance, failure, or contraindication to the required trial agents.
- Evidence that Myqorzo is not being used in combination with another cardiac myosin inhibitor (e.g., Camzyos/mavacamten).
- Prescribing or documented consultation by a cardiologist.
Triggers for denial
Requests may be denied if required baseline measurements, symptom class, prior therapy trials, or cardiology involvement are missing, or if Myqorzo is used with another cardiac myosin inhibitor.
- Absence of baseline LVEF or LVOT peak gradient measurements (LVEF ≥55% initial; LVOT ≥50 mmHg) prior to therapy.
- Patient outside NYHA class II–III.
- No documentation of prior trial, intolerance, failure, or contraindication to a non-vasodilating beta blocker or a nondihydropyridine calcium channel blocker.
- Concurrent use with another cardiac myosin inhibitor (e.g., Camzyos/mavacamten).
- Lack of prescribing or consultation by a cardiologist.
Key Definitions
Background
Myqorzo (aficamten) is a cardiac myosin inhibitor indicated for adults with symptomatic obstructive hypertrophic cardiomyopathy. The policy frames eligibility around patients with symptomatic oHCM (specifically NYHA class II–III) who have preserved systolic function and demonstrable left ventricular outflow tract obstruction; for initial therapy the policy requires a baseline LVEF ≥55% and an LVOT peak gradient of ≥50 mmHg at rest or with provocation. Prescribing or consultation by a cardiologist and prior trial/intolerance of specified negative inotropic agents are required before approval.
Revision History
Policy became effective for Myqorzo (aficamten) prior authorization and medical necessity criteria.
Clarified LVOT criteria prior to starting therapy without changing clinical criteria.
Program established as a new prior authorization/medical necessity policy for Myqorzo (aficamten) with P&T approval in February 2026.
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