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Elyxyb — Blue Cross Blue Shield of Alabama

other FDA labeled indication

Initial criteria

  • ONE of the following:
  • The requested agent is being used for acute migraine treatment AND ALL of the following:
  • • ONE of the following:
  • – The patient has tried and had an inadequate response to ONE prerequisite agent (any triptan agent or triptan combination) OR
  • – The patient has an intolerance or hypersensitivity to ONE prerequisite agent OR
  • – The patient has an FDA labeled contraindication to ALL prerequisite agent(s)
  • • ONE of the following:
  • – The requested agent is NOT REYVOW OR
  • – The requested agent is REYVOW AND the patient will NOT be using the requested agent in combination with another acute migraine therapy (i.e., 5HT-1F, acute use CGRP, ergotamine, triptan)
  • • Medication overuse headache has been ruled out
  • OR
  • The patient has another FDA labeled indication for the requested agent and route of administration OR
  • The patient has another indication that is supported in compendia for the requested agent and route of administration
  • AND
  • If the patient has an FDA labeled indication, then ONE of the following:
  • – The patient’s age is within FDA labeling for the requested indication for the requested agent OR
  • – There is support for using the requested agent for the patient’s age for the requested indication
  • AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent
  • Compendia Allowed: AHFS, or DrugDex 1 or 2a level of evidence

Reauthorization criteria

  • The patient has been approved for the requested agent previously through the plan’s Prior Authorization process
  • AND
  • ONE of the following:
  • The requested agent is being used for acute migraine treatment AND ALL of the following:
  • • The patient has had clinical benefit with the requested agent
  • • ONE of the following:
  • – The requested agent is NOT REYVOW OR
  • – The requested agent is REYVOW AND the patient will NOT be using the requested agent in combination with another acute migraine therapy (i.e., 5HT-1F, acute use CGRP, ergotamine, triptan)
  • • Medication overuse headache has been ruled out
  • OR
  • The patient has a diagnosis other than acute migraine treatment AND has had clinical benefit with the requested agent
  • AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent
  • Compendia Allowed: AHFS, or DrugDex 1 or 2a level of evidence

Approval duration

12 months