Corlanor/Ivabradine Prior Authorization (with Quantity Limit) Criteria – Medicare Part D

Corlanor oral solution and ivabradine tablets will be approved when ALL of the following are met:

1. The patient has stable, symptomatic chronic heart failure (e.g., NYHA Class II, III, IV: ACCF/AHA Class C, D) AND
2. ONE of following: 
   1. ALL of the following: 
      1. The requested medication is for a pediatric patient, at least 6 months of age AND 
      2. The patient has heart failure due to dilated cardiomyopathy (DCM) AND 
      3. The patient is in sinus rhythm with an elevated heart rate OR 
   2. ALL of the following: 
      1. The requested medication is for an adult patient AND 
      2. The patient has a baseline OR current left ventricular ejection fraction of 35% or less AND 
      3. The patient is in sinus rhythm with a resting heart rate of 70 beats or greater per minute prior to initiating therapy with the requested medication AND 
      4. ONE of the following: 
         1. The patient is on a maximally tolerated dose of beta blocker (e.g., bisoprolol, carvedilol, metoprolol) OR 
         2. The patient has an intolerance, FDA labeled contraindications, or hypersensitivity to a beta blocker AND 
3. The patient does NOT have any FDA labeled contraindications to the requested medication AND 
4. ONE of the following: 
   1. The requested quantity (dose) does NOT exceed the program quantity limit OR 
   2. ALL of the following: 
      1. The requested quantity (dose) is greater than the program quantity limit AND 
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit AND 
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months