CurrentUnitedHealthcarePolicy 2026 P 1391-5

Camzyos (mavacamten) prior authorization

Defines UnitedHealthcare prior authorization and reauthorization criteria for Camzyos (mavacamten) for adults with symptomatic NYHA class II-III obstructive hypertrophic cardiomyopathy; applies to providers submitting requests under UnitedHealthcare pharmacy/clinical programs.

Policy Summary

PayerUnitedHealthcare

PolicyCamzyos (mavacamten) prior authorization

Policy CodePolicy 2026 P 1391-5

Change TypeAddition — combination therapy exclusion

Effective DateMay 1, 2026

Next Review Date

Key ActionObtain prior authorization and document obstructive HCM with NYHA class II–III and ensure therapy is not used with another cardiac myosin inhibitor.

SourceLink

POLICY UPDATE CHANGES

Added criterion that Camzyos not be used in combination with another cardiac myosin inhibitor (e.g., Myqorzo/aficamten).

12 monthsauthorization period for initial approval

12 monthsauthorization period for reauthorization

NYHA II-IIIcovered symptomatic HF classes

Program 2026 P 1391-5policy identifier

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inv-01: COVERAGE CRITERIA

Covered when ALL of the following are met for initial authorization:

Initial Authorization

Diagnosis of obstructive hypertrophic cardiomyopathy (HCM)
NYHA class II OR NYHA class III heart failure
Combination therapy exclusion: Not used in combination with another cardiac myosin inhibitor (e.g., Myqorzo/aficamten)

inv-02: COVERAGE CRITERIA

Covered when ALL of the following are met for reauthorization:

Reauthorization

Clinical response: Documentation of positive clinical response to Camzyos therapy
Combination therapy exclusion: Not used in combination with another cardiac myosin inhibitor (e.g., Myqorzo/aficamten)

Requests for Camzyos (mavacamten) are excluded when prescribed in combination with another cardiac myosin inhibitor. The policy explicitly cites Myqorzo (aficamten) as an example of such a concurrent agent and states that therapy must not be used together with another cardiac myosin inhibitor for authorization to be issued.

The policy indicates that program-level edits may affect approvals: UnitedHealthcare may use prior claims/medication history, diagnosis codes, and claim logic to approve or deny requests. Additionally, supply limits and medical necessity edits may be in place; the document does not provide further details on the specific edits or thresholds.

Coding & Authorization Duration

No codes listed in documentmixed

No codes listed

Authorization duration

Authorization durationAuthorization will be issued for 12 months for initial and reauthorization approvals.

Initial authorization noteAuthorization for initial approval is issued for 12 months (see initial criteria).

Reauthorization noteAuthorization for reauthorization/continuation is issued for 12 months (documentation of positive clinical response required).

Provider Actions & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required. Initial requests must meet all initial authorization criteria below; approvals are issued for 12 months.

Camzyos requires prior authorization before initiation.
Initial authorization duration: 12 months.

Documentation Required

Reauthorization Requirements

Reauthorization requires documentation of a positive clinical response to Camzyos and confirmation that therapy is not being used in combination with another cardiac myosin inhibitor. Reauthorizations are issued for 12 months.

Documentation of positive clinical response to Camzyos required.
Reauthorization duration: 12 months.

Documentation Required

Initial Authorization Diagnosis and Class

Initial authorization will be approved only when ALL of the following are met: diagnosis of obstructive hypertrophic cardiomyopathy and heart failure classified as NYHA class II or III, and Camzyos is not used in combination with another cardiac myosin inhibitor (for example, Myqorzo/aficamten).

Diagnosis: obstructive hypertrophic cardiomyopathy (HCM).
NYHA class II OR NYHA class III heart failure.
Not used in combination with another cardiac myosin inhibitor (e.g., Myqorzo/aficamten).

Denial Risk

Combination Therapy Exclusion

Requests may be denied if Camzyos is prescribed in combination with another cardiac myosin inhibitor.

Combination therapy exclusion example: Myqorzo (aficamten).

Billing Rule

Supply Limits / Utilization Management

Supply limits and other utilization management edits (including medical necessity edits) may be applied. State mandates, federal requirements, member-specific benefit plan coverage, and other utilization management programs may also affect coverage and authorization decisions.

Supply limits and/or medical necessity edits may be in place.
State and federal mandates and member benefit plans may impact coverage.

Denial Risk

Automated Approval/Denial Risk

Authorizations (initial and reauthorization) may be approved or denied automatically based solely on claim/medication history, diagnosis codes (ICD-10), and claim logic. Automated processes vary by program and therapeutic class — providers should ensure claims and medication histories are complete and accurate.

Automated approval/denial may rely only on claims, medication history, diagnosis codes, and claim logic.
Use of automated approval/reapproval processes varies by program/therapeutic class.

Background

Mavacamten (Camzyos) is a cardiac myosin inhibitor indicated for adults with symptomatic obstructive hypertrophic cardiomyopathy (HCM) to improve functional capacity and symptoms. Under this policy, coverage is targeted to patients with NYHA class II or III symptoms and excludes concurrent use with other cardiac myosin inhibitors; when covered, authorization is issued for 12 months.

Definitions

Obstructive hypertrophic cardiomyopathy (HCM)

TermObstructive hypertrophic cardiomyopathy (HCM): a form of hypertrophic cardiomyopathy characterized by symptomatic left ventricular outflow tract obstruction; treated with agents like mavacamten to improve functional capacity in adults.

Indication contextCamzyos (mavacamten) is indicated for adults with symptomatic NYHA class II–III obstructive HCM to improve functional capacity and symptoms.

Combination therapy exclusionNot used in combination with another cardiac myosin inhibitor (e.g., Myqorzo/aficamten) — concurrent use is excluded under this policy.

NYHA class II–III

NYHA class IINew York Heart Association (NYHA) class II: symptomatic heart failure with slight limitation of physical activity (symptoms with ordinary activity).

NYHA class IIINew York Heart Association (NYHA) class III: symptomatic heart failure with marked limitation of physical activity (comfortable at rest; symptoms with less than ordinary activity).

Policy requirementCoverage under this policy is limited to adults with symptomatic NYHA class II or III heart failure due to obstructive HCM.

Initial Therapy

inv-17: Initial Therapy

Initial authorization — Covered when ALL of the following are met:

Initial Therapy

Diagnosis of obstructive hypertrophic cardiomyopathy (HCM)
NYHA class II OR NYHA class III heart failure
Combination therapy exclusion: Medication is not used in combination with another cardiac myosin inhibitor (e.g., Myqorzo/aficamten)

Reauthorization / Continuation Criteria

inv-18: Reauthorization

Reauthorization/continuation — Covered when ALL of the following are met:

Reauthorization

Clinical response: Documentation of positive clinical response to Camzyos therapy
Combination therapy exclusion: Medication is not used in combination with another cardiac myosin inhibitor (e.g., Myqorzo/aficamten)

Site of Care

Note

Office site — supply limits may be applied

Supply limits may be applied for office-administered therapy; the policy does not specify a required site of care.

Site of care not specified in the policy.

Policy Summary

PayerUnitedHealthcare

PolicyCamzyos (mavacamten) prior authorization

Policy CodePolicy 2026 P 1391-5

Change TypeAddition — combination therapy exclusion

Effective DateMay 1, 2026

Next Review Date

Key ActionObtain prior authorization and document obstructive HCM with NYHA class II–III and ensure therapy is not used with another cardiac myosin inhibitor.

SourceLink

On This Page

OpenPayer

Camzyos (mavacamten) prior authorization

Coverage Criteria

Coding & Authorization Duration

Provider Actions & Documentation Requirements

Background

Definitions

Initial Therapy

Reauthorization / Continuation Criteria

Site of Care