Elyxyb — Blue Cross Blue Shield of Kansas

acute migraine treatment

Preferred products

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. 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
B. The patient has an FDA labeled contraindication to ALL prerequisite agent(s) AND
2. ONE of the following:
A. The requested agent is NOT REYVOW OR
B. 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 AND
2. If the patient has an FDA labeled indication, then ONE of the following:
A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
B. There is support for using the requested agent for the patient’s age for the requested indication AND
3. The patient does NOT have any FDA labeled contraindications to the requested agent

Target Agent(s) will be approved when ALL of the following are met (see renewal criteria statement; details not given beyond this segment)

12 months