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Migranal (dihydroergotamine mesylate) — Blue Cross Blue Shield of Illinois

another indication supported in compendia for the requested agent and route of administration

Preferred products

  • any triptan agent or triptan combination

Initial criteria

  • ONE of the following:
  • A. The requested agent is being used for acute migraine treatment AND ALL of the following:
  • 1. ONE of the following:
  • A. BOTH of the following:
  • 1. ONE of the following:
  • A. The patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
  • B. The patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes are required] AND
  • 2. The use of the requested agent is consistent with best practices for the treatment of stage four advanced, metastatic cancer, or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by the United States Food and Drug Administration OR
  • B. The patient has ONE of the following:
  • 1. Has tried and had an inadequate response to ONE prerequisite agent OR
  • 2. Has an intolerance or hypersensitivity to ONE prerequisite agent OR
  • C. The patient has an FDA labeled contraindication to ALL prerequisite agent(s) AND
  • 2. ONE of the following:
  • 1. The requested agent is NOT REYVOW OR
  • 2. 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) AND
  • 3. Medication overuse headache has been ruled out OR
  • B. The patient has another FDA labeled indication for the requested agent and route of administration OR
  • C. The patient has another indication that is supported in compendia for the requested agent and route of administration