Pharmacy Prior Authorization Criteria

Camzyos (mavacamten) - PA, NF

Indications for Prior Authorization

Camzyos (mavacamten)

• For diagnosis of Obstructive hypertrophic cardiomyopathy (HCM)
  Indicated for the treatment of adults with symptomatic New York Heart Association (NYHA) class II-III obstructive hypertrophic cardiomyopathy (HCM) to improve functional capacity and symptoms.

Criteria

Camzyos

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

• Diagnosis of obstructive hypertrophic cardiomyopathy (HCM)
AND
• Patient has New York Heart Association (NYHA) Class II or III symptoms (e.g., shortness of breath, chest pain)
AND
• Patient has a left ventricular ejection fraction of greater than or equal to 55%
AND
• Patient has valsalva left ventricular outflow tract (LVOT) peak gradient greater than or equal to 50 mmHg at rest or with provocation
AND
• Trial and failure, contraindication, or intolerance to both of the following at a maximally tolerated dose: [C, 2]
• non-vasodilating beta blocker (e.g., bisoprolol, propranolol)
• calcium channel blocker (e.g., verapamil, diltiazem)
AND
• Prescribed by or in consultation with a cardiologist

Camzyos

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., improved symptom relief)
AND
• Patient has a left ventricular ejection fraction of greater than or equal to 50% [A, B, 1]
AND
• Prescribed by or in consultation with a cardiologist

Camzyos

Non Formulary (Initial Authorization)

Length of Approval: 6 Month(s)

• Diagnosis of obstructive hypertrophic cardiomyopathy (HCM)
AND
• Patient has New York Heart Association (NYHA) Class II or III symptoms (e.g., shortness of breath, chest pain)
AND
• Submission of medical records (e.g., chart notes) documenting patient has a left ventricular ejection fraction of greater than or equal to 55%
AND
• Submission of medical records (e.g., chart notes) documenting patient has valsalva left ventricular outflow tract (LVOT) peak gradient greater than or equal to 50 mmHg at rest or with provocation
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure, contraindication, or intolerance to both of the following at a maximally tolerated dose: [C, 2]
• non-vasodilating beta blocker (e.g., bisoprolol, propranolol)
• calcium channel blocker (e.g., verapamil, diltiazem)
AND
• Prescribed by or in consultation with a cardiologist

Camzyos

Non Formulary (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., improved symptom relief)
AND
• Submission of medical records (e.g., chart notes) documenting patient has a left ventricular ejection fraction of greater than or equal to 50% [A, B, 1]
AND
• Prescribed by or in consultation with a cardiologist

P & T Revisions

2025-08-06, 2024-07-02, 2023-09-13, 2023-06-14, 2022-10-04, 2022-08-16, 2022-07-05

References

1. Camzyos prescribing information. MyoKardia, Inc. Brisbane, CA. April 2025.
2. Ommen SR, Ho CY, Asif IM, et al. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(23).

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End Notes

1. Patients may develop heart failure while taking CAMZYOS. Regular LVEF and Valsalva left ventricular outflow tract (LVOT) gradient assessment is required for careful titration to achieve an appropriate target Valsalva LVOT gradient, while maintaining LVEF ≥50% and avoiding heart failure symptoms. [1]
2. If LVEF <50% while taking Camzyos, interrupt treatment. [1]
3. In general, nonvasodilating beta blockers are considered first-line therapy. The calcium channel blockers—verapamil or diltiazem—are reasonable alternatives to beta-blocker therapy. For patients who do not respond to trials of ≥1 of these drugs, advanced therapies with disopyramide, mavacamten (a cardiac myosin inhibitor), or septal reduction are often the next step. [2]

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Revision History

• 2025-08-06: 2025 Annual Review - updated references
• 2024-07-02: 2024 Annual Review - updated references
• 2023-09-13: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-06-14: 2023 Annual Review - no changes
• 2022-10-04: Addition of NF criteria
• 2022-08-16: Update to initial authorization duration and trial and failure criteria
• 2022-07-05: New program

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