Limited coverage criteria – ivabradine

ivabradine hydrochloride

5 mg, 7.5 mg tablet

For the treatment of stable heart failure (HF) in patients with New York Heart Association (NYHA) Class II or III HF, who are in the sinus rhythm, if all of the following criteria are met:

• Reduced left ventricular ejection fraction (≤35%)
   
• Resting heart rate documented to average ≥77 bpm using either continuous monitoring or an ECG on at least 3 separate visits. If another method is used, details must be provided on the Special Authority form
   
• NYHA Class II or III symptoms have persisted despite at least four weeks of treatment at the optimum stable doses of a combination of:

• an angiotensin-converting enzyme inhibitor or an angiotensin II receptor antagonist, AND

• a beta blocker, AND

• an aldosterone antagonist, if tolerated

• When coverage of ivabradine for the treatment of HF is requested by a cardiologist or an internal medicine specialist

Indefinite