Elyxyb — Blue Cross Blue Shield of Kansas

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. 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

Reauthorization criteria

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

Approval duration

12 months