CurrentWashington State Health Care AuthorityPolicy 40.90.00-1

Cardiovascular Agents - Vasoactive Soluble Guanylate Cyclase Stimulators

Customize your policy alerts

Sign up for Washington State Health Care Authority Policy 40.90.00-1 alerts

Get alerted when Policy 40.90.00-1 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Prior authorization and medical necessity coverage for vericiguat (Verquvo) for Apple Health members, including preferred-drug requirements, clinical eligibility, reauthorization, and quantity limits.

Policy Summary

PayerWashington State Health Care Authority

PolicyCardiovascular Agents - Vasoactive Soluble Guanylate Cyclase Stimulators

Policy CodePolicy 40.90.00-1

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateNot specified

Key ActionSubmit documentation demonstrating disease stability or a positive clinical response for reauthorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 drugDrug specifically addressed

EF <45%Required ejection fraction

NYHA II-IV

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentWashington State Health Care AuthorityPolicy 40.90.00-1

Cardiovascular Agents - Vasoactive Soluble Guanylate Cyclase Stimulators

Customize your policy alerts

Sign up for Washington State Health Care Authority Policy 40.90.00-1 alerts

Get alerted when Policy 40.90.00-1 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerWashington State Health Care Authority

PolicyCardiovascular Agents - Vasoactive Soluble Guanylate Cyclase Stimulators

Policy CodePolicy 40.90.00-1

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateNot specified

Key ActionSubmit documentation demonstrating disease stability or a positive clinical response for reauthorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 drugDrug specifically addressed

EF <45%Required ejection fraction

NYHA II-IV

Heart-failure classification

12 monthsAuthorization duration

30 tabletsQuantity limit per strength

Coverage Criteria Overview

Initial Therapy

Covered when ALL of the following documented criteria are met:

ALL of the following

Patient is 18 years of age or older.>= 18 years
Prescribed by, or in consultation with, a cardiologist.
Diagnosis of chronic heart failure with reduced ejection fraction.
Patient has an ejection fraction less than 45%.< 45%
Patient has a New York Heart Association (NYHA) Classification II-IV.
ONE of the following
- Patient is prescribed vericiguat following a hospitalization due to heart failure.
- Patient is prescribed vericiguat following outpatient use of intravenous diuretics.
ALL of the following optimized-dose therapies, unless contraindicated or not tolerated
- Provider attests or documentation demonstrates management with a beta-blocker at an optimized dose, unless contraindicated or not tolerated (e.g., carvedilol, metoprolol, bisoprolol).
- Provider attests or documentation demonstrates management with an inhibitor of the renin-angiotensin system at an optimized dose, unless contraindicated or not tolerated (e.g., angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker).
- Provider attests or documentation demonstrates management with a mineralocorticoid receptor antagonist at an optimized dose, unless contraindicated or not tolerated (e.g., spironolactone).

Continuation Therapy

Covered when ALL of the following documented criteria are met:

ALL of the following

Documentation is submitted demonstrating disease stability or a positive clinical response (e.g., the patient has documented improvement or stability of disease since starting vericiguat).

Coding and Clinical Parameters

Codingmixed

N/A

Ejection fraction

Required ejection fractionLess than 45%

Clinical conditionChronic heart failure with reduced ejection fraction

DocumentationThe patient’s ejection fraction must be documented as below 45%

NYHA classification

ClassificationNew York Heart Association (NYHA) functional classification

Qualifying rangeClass II through Class IV

Requirement

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required for Non-Preferred Agents

New-to-market drugs included in this class on the Apple Health Preferred Drug List are non-preferred and require prior authorization.

Non-preferred agents require an inadequate response or documented intolerance due to a severe adverse reaction or contraindication to at least two preferred agents.
If only one preferred agent is available in the class, documentation of inadequate response to that one preferred agent is required.
See the current Apple Health Preferred Drug List (AHPDL) for preferred-agent status.

Note

Medical Necessity Review

Vericiguat (Verquvo) may be considered medically necessary when the applicable clinical criteria are met. If all criteria are not met, a clinical reviewer may determine that the drug is medically necessary and approve the request on a case-by-case basis.

Non-preferred brand-name products on the Apple Health Drug List with an A-rated generic, biosimilar, or interchangeable biosimilar must also meet Non-Clinical Policy No. 0001 (NC-001).

Clinical Background

Vericiguat (Verquvo) is a vasoactive soluble guanylate cyclase stimulator used in adults with symptomatic chronic heart failure and reduced left ventricular ejection fraction. Clinical evidence evaluated patients with NYHA class II-IV disease and LVEF below 45% after a worsening heart-failure event, defined as a recent heart-failure hospitalization or outpatient intravenous diuretic use. Participants commonly received background heart-failure therapy, including beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists. In the pivotal trial, vericiguat reduced the annualized composite risk of cardiovascular death or heart-failure hospitalization compared with placebo.

Definitions

Worsening heart-failure event

DefinitionA worsening heart-failure event is a heart-failure hospitalization within 6 months before treatment or outpatient use of intravenous diuretics for heart failure within 3 months before treatment

Hospitalization exampleHospitalization due to heart failure within the preceding 6 months

Outpatient-treatment exampleUse of outpatient intravenous diuretics for heart failure within the preceding 3 months

NYHA II-IV

Classification systemNew York Heart Association functional classification

Qualifying classesClasses II through IV

Initial Therapy for Chronic HFrEF

Vericiguat may be approved when all clinical criteria are met:

Patient and prescriber requirements: Patient is 18 years of age or older AND vericiguat is prescribed by, or in consultation with, a cardiologist>=18 years

Disease criteria: Patient has chronic heart failure with reduced ejection fraction, with an ejection fraction less than 45% and New York Heart Association (NYHA) Classification II-IVEF <45%; NYHA II-IV

Recent worsening heart-failure event

Hospitalization due to heart failure

Vericiguat Reauthorization

Reauthorization may be approved when the following is documented:

Continuation response: Documentation is submitted demonstrating disease stability or a positive clinical response since starting vericiguatDocumented improvement or stability

If the criterion is met, the request is authorized for 12 months.

Preferred-Agent Requirements

Step	Requirement	Exception
1	Before a non-preferred agent is authorized, document an inadequate response or intolerance due to a severe adverse reaction or contraindication to at least two preferred agents.	If only one preferred agent exists in the class, document an inadequate response or intolerance to that one preferred agent.

Verquvo Quantity Limits

Verquvo 2.5 mg tablets

StrengthVerquvo (vericiguat) 2.5 mg tablets

Quantity limit30 tablets per day

Dosage formTablets

Verquvo 5 mg tablets

StrengthVerquvo (vericiguat) 5 mg tablets

Quantity limit30 tablets per day

Dosage formTablets

Policy Summary

PayerWashington State Health Care Authority

PolicyCardiovascular Agents - Vasoactive Soluble Guanylate Cyclase Stimulators

Policy CodePolicy 40.90.00-1

Change TypeNo material change

Effective DateApr 1, 2026

Next Review DateNot specified

Key ActionSubmit documentation demonstrating disease stability or a positive clinical response for reauthorization.

SourceLink

On This Page

The patient must have NYHA Classification II-IV

Age

Minimum age18 years

EligibilityPatient is 18 years of age or older

PopulationAdult patients

Verquvo quantity limit

2.5 mg tablets30 tablets per day

5 mg tablets30 tablets per day

10 mg tablets30 tablets per day

For a patient previously established on therapy who is new to Apple Health, the clinical reviewer may use the reauthorization criteria.

Prior Authorization

Authorization Duration

Requests meeting all initial or reauthorization criteria are authorized for 12 months.

Initial authorization: 12 months.
Reauthorization: 12 months when continuation criteria are met.

Step Therapy

Preferred-Agent Step Requirement

Before a non-preferred agent can be authorized, the provider must document an inadequate response or documented intolerance to the required preferred agents.

Document failure, severe adverse reaction, or contraindication to at least two preferred agents.
If the class has only one preferred agent, document inadequate response to that one agent.

Documentation Required

Initial Clinical Documentation

Submit documentation with the initial request showing that the patient meets the clinical criteria for vericiguat (Verquvo) for chronic heart failure with reduced ejection fraction.

Patient is 18 years of age or older.
Vericiguat is prescribed by, or in consultation with, a cardiologist.
Diagnosis of chronic heart failure with reduced ejection fraction.
Ejection fraction is less than 45%.
New York Heart Association (NYHA) Classification II-IV.
Vericiguat is prescribed following either a hospitalization due to heart failure or outpatient use of intravenous diuretics.

Documentation Required

Optimized Background Therapy

The provider must attest, or submit documentation, that the patient is managed with the following therapies at optimized doses unless contraindicated or not tolerated.

Beta-blocker, such as carvedilol, metoprolol, or bisoprolol.
Inhibitor of the renin-angiotensin system, such as an angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker.
Mineralocorticoid receptor antagonist, such as spironolactone.

Documentation Required

Reauthorization Response Documentation

For reauthorization, submit documentation demonstrating disease stability or a positive clinical response since vericiguat was started.

Examples include documented improvement or stability of disease.

Step Therapy

Preferred-Agent Failure Documentation

For a non-preferred agent, document failure, intolerance due to a severe adverse reaction, or contraindication to the required preferred agents before requesting authorization.

Document inadequate response or documented intolerance to at least two preferred agents.
When only one preferred agent is available, document inadequate response to that one preferred agent.

Denial Risk

Initial Clinical Criteria Not Met

An initial request may be denied when the submitted documentation does not establish all required clinical criteria for vericiguat.

Any initial criterion may result in denial if not documented: age 18 or older; cardiologist prescribing or consultation; chronic heart failure with reduced ejection fraction; ejection fraction less than 45%; NYHA Classification II-IV; qualifying heart-failure hospitalization or outpatient intravenous diuretic use; and optimized background therapy unless contraindicated or not tolerated.

Denial Risk

Insufficient Continuation Response Documentation

A reauthorization request may be denied when documentation does not demonstrate disease stability or a positive clinical response to vericiguat.

Submit evidence of improvement or stability of disease since treatment began.

Billing Rule

Additional Non-Clinical Policy Requirement

Non-preferred brand-name products on the Apple Health Drug List with an A-rated generic, biosimilar, or interchangeable biosimilar must also meet Non-Clinical Policy No. 0001 (NC-001).

This additional non-clinical policy requirement applies in addition to the clinical criteria for vericiguat.
If a new FDA-approved indication is added, medical necessity for that indication is determined case-by-case under FDA labeling.

NYHA Classification II-IV

Outpatient use of intravenous diuretics

Optimized background therapy: Provider attests or documentation shows that the patient is being managed with all of the following at optimized doses unless contraindicated or not tolerated: beta-blocker; inhibitor of the renin-angiotensin system; and mineralocorticoid receptor antagonist

Examples include carvedilol, metoprolol, or bisoprolol; an angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker; and spironolactone.

Verquvo 10 mg tablets

StrengthVerquvo (vericiguat) 10 mg tablets

Quantity limit30 tablets per day

Dosage formTablets