Pharmacy Prior Authorization Criteria

Cardamyst (etripamil) nasal solution

Indications for Prior Authorization

Cardamyst (etripamil)

• For diagnosis of Paroxysmal supraventricular tachycardia (PSVT)
  Indicated for the conversion of acute symptomatic episodes of paroxysmal supraventricular tachycardia (PSVT) to sinus rhythm in adults

Criteria

Cardamyst

Prior Authorization

Length of Approval: 6 Month(s)

• Diagnosis of paroxysmal supraventricular tachycardia (PSVT)
AND
• Patient has had prior sustained symptomatic episodes lasting greater than or equal to 20 minutes [A]
AND
• Drug will be used for conversion of acute symptomatic episodes of PSVT to sinus rhythm
AND
• Patient does not have any contraindication to etripamil (e.g., Heart failure, Wolff-Parkinson-White (WPW), Lown-Ganong-Levine (LGL) syndromes)
AND
• Prescribed by or in consultation with one of the following:
• Cardiologist
• Electrophysiologist
• Emergency medicine physician

P & T Revisions

2026-02-20

References

1. Cardamyst prescribing information. Milestone Pharmaceuticals USA, Inc. Charlotte, NC. December 2025.
2. Stambler BS, Camm AJ, Alings M, et. al.; RAPID Investigators. Self-administered intranasal etripamil using a symptom-prompted, repeat-dose regimen for atrioventricular-nodal-dependent supraventricular tachycardia (RAPID): a multicentre, randomised trial. Lancet. 2023 Jul 8;402(10396):118-128.
3. Clinical consult with cardiologist, January 29, 2026.

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End Notes

1. In the pivotal study for Cardamyst (etripamil), eligible patients were 18 years of age or older and had a history of paroxysmal supraventricular tachycardia with sustained, symptomatic episodes (lasting greater than or equal to 20 minutes). [2, 3]

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Revision History

• 2026-02-20: New program.

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