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L.5.01.414
Corlanor (ivabradine)
Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
Ivabradine is a hyperpolarization-activated cyclic nucleotide-gated channel blocker that reduces the spontaneous pacemaker activity of the cardiac sinus node by selectively inhibiting the If current, resulting in heart rate reduction with no effect on ventricular repolarization and no effects on myocardial contractility. Ivabradine is indicated to reduce the risk of hospitalization for worsening heart failure in adult patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction ≤35%, who are in sinus rhythm with resting heart rate ≥70 beats per minute, and either are on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use. Ivabradine is also indicated for the treatment of stable symptomatic heart failure due to dilated cardiomyopathy (DCM) in pediatric patients aged 6 months and older, who are in sinus rhythm with an elevated heart rate. Additionally, ivabradine is included as a supported therapy for symptomatic inappropriate sinus tachycardia in the 2015 American College of Cardiology, American Heart Association, and Heart Rhythm Society Guideline for the Management of Adult Patients with Supraventricular Tachycardia.
Prior authorization is required.
The use of samples by an individual will not be considered current or stable therapy to satisfy Medical Policy requirements.
Corlanor (ivabradine) may be considered medically necessary when ALL of the following criteria are met:
ONE of the following:
The individual is >18 years old and has a documented diagnosis of symptomatic chronic heart failure (NYHA class II- IV) with left ventricular ejection fraction ≤35% and BOTH of the following:
The individual is in sinus rhythm with a resting heart rate ≥70 beats or more per minute; AND
The individual is on maximally tolerated doses of beta blockers OR has a contraindication to beta blockers (i.e. cardiogenic shock or overt cardiac failure, severe sinus bradycardia, second and third degree heart block, bronchial asthma or chronic obstructive pulmonary disease);
The individual is >6 months old to <18 years old and has a documented diagnosis of stable symptomatic heart failure (NYHA class II-IV) due to dilated cardiomyopathy (DCM) with left ventricular ejection fraction <45% and BOTH of the following:
The individual is in sinus rhythm with an elevated heart rate (see Policy Guidelines below); AND
If the request is for oral solution, the individual weighs less than 40kg;
OR
The individual >18 years old and has a diagnosis of inappropriate sinus tachycardia (IST) and ONE of the following:
The individual has tried or is currently receiving a beta blocker (i.e., metoprolol, bisoprolol, etc.) for IST; OR
The individual has a contraindication to the use of beta blocker therapy (i.e. cardiogenic shock or overt cardiac failure, severe sinus bradycardia, second and third degree heart block, bronchial asthma or chronic obstructive pulmonary disease);
The prescriber is a board certified cardiologist or has consulted with a board certified cardiologist;
The individual does not have any contraindication(s) to therapy with the requested agent; AND
The prescribed dosage is within the program quantity limits based on FDA approved labeled dosage.
Length of Approval: 12 months
Renewal Criteria
Corlanor (ivabradine) may be approved for RENEWAL when ALL of the following criteria are met:
The individual has been previously approved for therapy through the BCBSMS PA process;
The individual’s condition has improved or stabilized;
The individual does not have any FDA-labeled contraindication(s) to therapy with the requested agent; AND
The prescribed dosage is within the program quantity limits based on FDA approved labeled dosage.
Length of Approval: 12 months
State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
Elevated heart rate for pediatric patients in sinus rhythm with stable symptomatic heart failure due to DCM is defined as follows:
HR > 105 bpm in the age-subset 6-12 months
HR > 95 bpm in the age-subset 1-3 years
HR > 75 bpm in the age-subset 3-5 years
HR > 70 bpm in the age-subset 5-18 years
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary. BCBSMS may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
BCBSMS determines patient medication trial and adherence by a review of pharmacy claims data over the preceding twelve months. Additional information may be requested on a case-by-case basis to allow for proper review. If member is new to BCBSMS and pharmacy records are needed to confirm medication trials and adherence, it is the responsibility of the member and/or requesting provider to obtain said records and to submit them to BCBSMS upon request. Medical records from the provider that list previously prescribed medications will not be sufficient to show medication trials or adherence.
10/01/2015: New policy added.
02/02/2016: Approved by Pharmacy & Therapeutics (P&T) Committee.
05/26/2016: Policy number L.5.01.414 added.
02/07/2017: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.
02/06/2018: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.
02/05/2019: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Added statement to perform a formulary drug search on the patient's member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member's benefit plan. Revised policy statement to state that the use of samples by a Member will not be considered current or stable therapy for purposes of Medical Policy review. Sources updated. Effective 01/01/2019.
11/01/2020: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Policy description updated regarding indications for Corlanor. Medically necessary statement updated to include age criteria. Policy statement criteria updated to list conditions in which Corlanor (ivabradine) will not be approved. Policy Exceptions updated to remove FEP and State Health Plan members. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders." Added information regarding sinus rhythm for pediatric patients with symptomatic heart failure and BCBSMS request for medical records. Sources updated.
02/01/2023: Policy Exceptions updated to add the following: State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
01/15/2025: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Policy description updated to remove "Corlanor." Policy statement revised to state that the use of samples by an individual will not be considered current or stable therapy to satisfy Medical Policy requirements. Policy statements revised to remove Corlanor coverage. Medically necessary criteria revised regarding the following: documentation of diagnosis, age requirement, prescriber information, contraindications, and dose requirements. Added renewal criteria and length of approval. Removed list of conditions in which Corlanor (ivabradine) will not be approved. Sources updated.
12/02/2025: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy description updated regarding ivabradine. Medically necessary policy criteria updated regarding individuals with a diagnosis of stable symptomatic heart failure and a diagnosis of inappropriate sinus tachycardia. Policy Guidelines updated. Sources updated.
Corlanor prescribing information. Amgen Inc. February 2022. Last accessed September 2025.
Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2016; 133:e506.
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