CurrentUnitedHealthcarePolicy N/A

Verquvo (vericiguat) prior authorization

Defines UnitedHealthcare prior authorization requirements for Verquvo (vericiguat) for adults with symptomatic chronic heart failure with reduced ejection fraction; applies to pharmacy benefit prior authorization/notification programs.

Policy Summary

PayerUnitedHealthcare

PolicyVerquvo (vericiguat) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2025

Next Review DateFeb 1, 2025

Key ActionObtain prior authorization and document symptomatic heart failure with EF <45%, NYHA class II–IV, and qualifying recent decompensation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

EF <45%EF threshold

6 monthsHF hospitalization window

3 monthsOutpatient IV diuretics window

Coverage Criteria for Verquvo (vericiguat)

Initial Authorization

Covered when ALL of the following are met:

Initial Authorization Criteria: Member has a diagnosis of symptomatic heart failure.

Ejection fraction is less than 45%.< 45%

Heart failure classified as New York Heart Association (NYHA) class II OR III OR IV.

Recent heart failure decompensation (ONE of):

ONE of: Hospitalization for heart failure within the past 6 months.

Policy Summary

PayerUnitedHealthcare

PolicyVerquvo (vericiguat) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 1, 2025

Next Review DateFeb 1, 2025

Key ActionObtain prior authorization and document symptomatic heart failure with EF <45%, NYHA class II–IV, and qualifying recent decompensation.

SourceLink

On This Page

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Outpatient intravenous (IV) diuretics for heart failure within the past 3 months.

Reauthorization

Covered when the following are met:

Reauthorization Criteria: Documentation of a positive clinical response to Verquvo therapy.

Authorization will be issued for 12 months

Verquvo (vericiguat) has a boxed warning for embryo-fetal toxicity. Use of Verquvo during pregnancy is contraindicated and the drug should not be used in pregnant individuals.

Coding and Clinical Thresholds

No specific billing codes listedmixed

No codes listed

Ejection fraction

Ejection fraction thresholdEF < 45%

Source criterionEjection fraction is less than 45 percent (documented)

Authorization duration when criteria metAuthorization issued for 12 months

Provider Requirements and Authorization Process

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Pharmacy prior authorization/notification program applies. Verquvo (vericiguat) requires prior authorization under UnitedHealthcare's pharmacy clinical programs. Providers must obtain approval before dispensing to ensure coverage.

Program: Prior Authorization/Notification
Medication: Verquvo (vericiguat)
P&T Approval Date: 11/2024
Effective Date: 2025-02-01

Note

Automated Approval / Re-approval Processes

Automated approval/re-approval processes may be used. UnitedHealthcare may approve initial and re-authorization decisions based solely on claim or medication history, diagnosis codes (ICD-10), and claim logic; use of these automated processes varies by program and therapeutic class. Providers should ensure accurate claims and coding to facilitate automated approvals.

Automated approvals may use prior claim/medication history
Diagnosis codes (ICD-10) and claim logic can trigger approvals
Process availability varies by program/therapeutic class

Documentation Required

Documentation Requirements

Documentation requirements: Medical record must demonstrate the clinical criteria for Verquvo therapy. At a minimum, include diagnosis and objective measures of systolic dysfunction, functional class, and recent decompensation events.

Documented diagnosis of symptomatic heart failure
Ejection fraction < 45% (EF documented in record)
NYHA functional class II, III, or IV
Evidence of recent decompensation: hospitalization for heart failure within past 6 months or outpatient IV diuretics within past 3 months
Authorization duration: up to 12 months for initial approval

Denial Risk

Denial Risk — Failure to document symptomatic heart failure with EF <45% or qualifying recent decompensation may result in denial of coverage. Absence of required clinical documentation or lack of evidence of positive response on reauthorization requests increases risk of denial.

Lack of EF <45% documentation increases denial risk
No record of NYHA class II–IV may lead to denial
Failure to show hospitalization within 6 months or outpatient IV diuretics within 3 months for initial requests may result in denial
Reauthorization requires documented positive clinical response

Background

Verquvo (vericiguat) is indicated to reduce the risk of cardiovascular death and heart failure (HF) hospitalization in adults with symptomatic chronic heart failure and an ejection fraction <45%. The indication applies to patients following a hospitalization for heart failure or those needing outpatient IV diuretics. Verquvo carries a boxed warning for embryo-fetal toxicity and is contraindicated in pregnancy.

Definitions

Symptomatic chronic heart failure (NYHA II–IV)

DefinitionHeart failure in adults presenting with symptoms and New York Heart Association functional class II–IV.

Required clinical classificationNYHA Class II, III, or IV (documented)

Associated eligibility requirementsMust have symptomatic chronic heart failure plus qualifying recent decompensation (HF hospitalization within 6 months or outpatient IV diuretics within 3 months)