Skip to content
The Policy VaultThe Policy Vault

Nurtec ODT — Blue Cross Blue Shield of Alabama

Chronic migraine prophylaxis

Preferred products

  • Aimovig
  • Ajovy
  • Emgality
  • Qulipta
  • Nurtec ODT
  • Ubrelvy

Initial criteria

  • ONE of the following:
  • • The requested agent is being used for migraine prophylaxis AND BOTH of the following:
  •   - ONE of the following: The requested agent is eligible for continuation of therapy AND ONE of the following: patient has been treated with the requested agent within the past 90 days OR prescriber states patient has been treated within past 90 days and is at risk if therapy is changed
  •   - ALL of the following (for new starts, not continuation):
  •     • ONE of the following:
  •       - Patient has at least 15 headache days per month of migraine-like or tension-like headache for ≥3 months (chronic migraine) AND at least 8 migraine headache days per month for ≥3 months AND requested agent/strength is FDA labeled for chronic migraine prophylaxis
  •       - BOTH of the following: Patient has 4–14 monthly migraine days (episodic migraine) AND requested agent/strength is FDA labeled for episodic migraine prophylaxis
  •     • If client has preferred agent(s), then ONE of the following:
  •       - Requested agent is a preferred agent or stand‑alone agent for the requested indication OR
  •       - Patient has tried and had inadequate response to ONE preferred agent for the indication OR has intolerance/hypersensitivity to ONE preferred agent OR has FDA labeled contraindication to ALL preferred agents
  •     • Medication overuse headache ruled out
  •     • Patient will NOT use the requested agent in combination with another prophylactic‑use CGRP
  • • The requested agent is being used for episodic cluster headache AND ALL of the following:
  •   - Patient has had ≥5 cluster headache attacks
  •   - Patient has ≥2 cluster periods lasting 7–365 days
  •   - Cluster periods are separated by pain‑free remission ≥3 months
  •   - ONE of the following: patient has tried and had inadequate response to ONE prerequisite agent (verapamil, melatonin, corticosteroids, topiramate, lithium) OR intolerance/hypersensitivity to ONE prerequisite agent OR FDA labeled contraindication to ALL prerequisite agents
  •   - Requested agent/strength FDA labeled for episodic cluster headache treatment
  •   - Medication overuse headache ruled out
  • • The requested agent is being used for acute migraine treatment AND ALL of the following:
  •   - ONE of the following: patient tried and had inadequate response to ONE triptan OR intolerance/hypersensitivity to ONE triptan OR FDA labeled contraindication to ALL triptans
  •   - Patient will NOT use requested agent in combination with another acute migraine therapy (5HT‑1F, acute‑use CGRP, ergotamine)
  •   - If client has preferred agent(s), then ONE of the following: requested agent is preferred/stand‑alone OR patient has tried and had inadequate response to ONE preferred agent OR intolerance/hypersensitivity OR contraindication to ALL preferred agents
  •   - Requested agent/strength FDA labeled for acute migraine treatment
  •   - Medication overuse headache ruled out
  • • The patient has another FDA labeled or compendia‑supported indication AND BOTH of the following: patient’s age is within or supported for use; no FDA labeled contraindications

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s PA process AND ONE of the following:
  • • Requested agent used for migraine prophylaxis AND ALL of the following:
  •   - Clinical benefit with the requested agent
  •   - NOT used in combination with another prophylactic‑use CGRP
  •   - ONE of the following:
  •     • Diagnosis chronic migraine (≥15 headache days/month for ≥3 months prior to prevention) AND requested agent/strength FDA labeled for chronic migraine
  •     • Diagnosis episodic migraine (4–14 monthly migraine days prior to prevention) AND requested agent/strength FDA labeled for episodic migraine
  • • Requested agent used for episodic cluster headache AND BOTH: clinical benefit and agent/strength FDA labeled for episodic cluster headache
  • • Requested agent used for acute migraine AND ALL: clinical benefit, not used with another acute migraine therapy (5HT‑1F, acute‑use CGRP, ergotamine), agent/strength FDA labeled for acute migraine, and medication overuse headache ruled out
  • • Patient has other indication and has had clinical benefit and no FDA labeled contraindications

Approval duration

6 months (migraine prophylaxis); 12 months (all other); renewal 12 months