Skip to content
The Policy VaultThe Policy Vault

Qulipta — Blue Cross Blue Shield of Illinois

Episodic cluster headache

Preferred products

  • Aimovig
  • Ajovy
  • Emgality
  • Nurtec ODT
  • Ubrelvy
  • Zavzpret

Initial criteria

  • ONE of the following:
  • A. The requested agent is being used for migraine prophylaxis AND BOTH of the following:
  • 1. ONE of the following:
  • A. The requested agent is eligible for continuation of therapy and the prescriber states the patient has been treated with the requested agent (not samples) within the past 90 days and is at risk if therapy is changed OR
  • B. Patient meets diagnostic criteria for chronic or episodic migraine (≥15 headache days per month for chronic, 4–14 for episodic) AND the requested agent and strength are FDA labeled for that use
  • AND
  • 2. ONE of the following:
  • A. The requested agent is a preferred agent or stand-alone agent for the requested indication OR
  • B. The patient has stage IV advanced metastatic cancer and use is consistent with best practices, peer-reviewed evidence, and FDA approval OR
  • C. The patient is currently being treated and stable on the requested agent OR
  • D. The patient has tried and had an inadequate response, intolerance, hypersensitivity, or contraindication to at least ONE preferred agent for the requested indication OR one preferred agent discontinued or expected to be ineffective/not in best interest OR another prescription drug in same class discontinued due to adverse event
  • AND
  • 3. Medication overuse headache has been ruled out AND the patient will NOT be using the requested agent in combination with another prophylactic CGRP
  • OR
  • B. The requested agent is being used for episodic cluster headache AND ALL of the following:
  • 1. The patient has had at least 5 cluster headache attacks
  • 2. At least two cluster periods lasting 7–365 days
  • 3. Cluster periods separated by remission ≥3 months
  • 4. ONE of the following: stage IV cancer criteria OR inadequate response/intolerance/contraindication to ONE prerequisite agent (verapamil, melatonin, corticosteroids, topiramate, lithium)
  • 5. The requested agent and strength are FDA labeled for episodic cluster headache treatment
  • 6. Medication overuse headache has been ruled out
  • OR
  • C. The requested agent is being used for acute migraine treatment AND ALL of the following:
  • 1. ONE of the following: stage IV cancer criteria OR inadequate response/intolerance/contraindication to ONE triptan agent
  • 2. Patient will NOT use with another acute migraine therapy (5HT-1F, acute CGRP, ergotamine)
  • 3. ONE of the following: requested agent is a preferred or stand-alone agent OR meets the metastatic cancer/medical necessity exception criteria listed above
  • 4. The requested agent and strength are FDA labeled for acute migraine treatment
  • 5. Medication overuse headache has been ruled out
  • OR
  • D. The patient has another FDA labeled or compendia-supported indication for the requested agent and route of administration
  • AND the patient's age is within or supported for the labeled indication and there are no labeled contraindications

Reauthorization criteria

  • Continuation of therapy is allowed when prescriber states the patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed
  • Patient remains stable or continues to benefit from therapy
  • No new contraindications, and the use remains consistent with labeled indication or compendia support

Approval duration

12 months (BCBSIL); 6 months for migraine prophylaxis and 12 months for other indications for all other plans