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Zavzpret — Blue Cross Blue Shield of Kansas

Episodic migraine prophylaxis

Preferred products

  • Aimovig
  • Ajovy
  • Emgality
  • Nurtec ODT

Initial criteria

  • 1. 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 ONE of the following:
  • - The patient has been treated with the requested agent (no sample starts) within the past 90 days OR
  • - The prescriber states patient has been treated with requested agent (no sample starts) within the past 90 days and is at risk if changed
  • OR
  • B. ALL of the following:
  • 1. ONE of the following:
  • A. The patient has ≥15 headache days per month for ≥3 months (chronic migraine) AND has ≥8 migraine headache days per month AND requested agent/strength is FDA labeled for chronic migraine prophylaxis OR
  • B. The patient has 4–14 monthly migraine days (episodic migraine) AND requested agent/strength is FDA labeled for episodic migraine prophylaxis
  • AND
  • 2. If the client has preferred agent(s), then ONE of the following:
  • A. The requested agent is a preferred or stand-alone agent OR
  • B. The patient has tried and had inadequate response to ONE preferred agent for the indication OR
  • C. The patient has intolerance or hypersensitivity to ONE preferred agent for the indication OR
  • D. The patient has an FDA labeled contraindication to ALL preferred agents for the indication
  • AND
  • 3. Medication overuse headache has been ruled out
  • AND
  • 2. The patient will NOT be using the requested agent in combination with another prophylactic use CGRP
  • OR
  • B. The requested agent is used for episodic cluster headache AND ALL of the following:
  • 1. ≥5 cluster headache attacks AND
  • 2. ≥2 cluster periods lasting 7–365 days AND
  • 3. Cluster periods separated by pain-free remission ≥3 months AND
  • 4. ONE of the following:
  • A. The patient has tried and had inadequate response to ONE prerequisite agent (verapamil, melatonin, corticosteroids, topiramate, lithium) OR
  • B. The patient has intolerance or hypersensitivity to ONE prerequisite agent OR
  • C. The patient has an FDA labeled contraindication to ALL prerequisite agents
  • 5. Requested agent/strength FDA labeled for episodic cluster headache treatment AND
  • 6. Medication overuse headache ruled out
  • OR
  • C. The requested agent is used for acute migraine treatment AND ALL of the following:
  • 1. ONE of the following:
  • A. The patient has tried and had inadequate response to ONE triptan OR
  • B. The patient has intolerance or hypersensitivity to ONE triptan OR
  • C. The patient has FDA labeled contraindication to ALL triptan agents
  • 2. The patient will NOT use the requested agent in combination with another acute migraine therapy (5HT-1F, acute CGRP, ergotamine) AND
  • 3. If client has preferred agent(s), ONE of the following:
  • A. Requested agent is preferred or stand-alone OR
  • B. Patient has tried and had inadequate response to ONE preferred agent OR
  • C. Patient has intolerance/hypersensitivity to ONE preferred agent OR
  • D. Patient has FDA labeled contraindication to ALL preferred agents
  • 4. Requested agent/strength FDA labeled for acute migraine treatment AND
  • 5. Medication overuse headache ruled out
  • OR
  • D. Patient has another FDA labeled indication for the requested agent and route OR
  • E. Patient has another indication supported in AHFS or DrugDex (level 1 or 2a)
  • AND
  • 2. If patient has FDA labeled indication, ONE of:
  • A. Age within FDA labeling OR
  • B. Support for use at patient’s age
  • AND
  • 3. Patient has no FDA labeled contraindications

Reauthorization criteria

  • 1. Patient previously approved for requested agent through PA process AND
  • 2. ONE of the following:
  • A. If used for migraine prophylaxis:
  • - Patient has clinical benefit AND
  • - Not using with another prophylactic CGRP AND
  • - ONE of:
  • • Chronic migraine (≥15 headache days/month for ≥3 months) AND requested agent/strength FDA labeled for chronic migraine OR
  • • Episodic migraine (4–14 monthly migraine days) AND requested agent/strength FDA labeled for episodic migraine
  • OR
  • B. If used for episodic cluster headache treatment:
  • - Patient has clinical benefit AND
  • - Requested agent/strength FDA labeled for episodic cluster headache
  • OR
  • C. If used for acute migraine treatment:
  • - Patient has clinical benefit AND
  • - Not using with another acute migraine therapy (5HT-1F, acute CGRP, ergotamine) AND
  • - Requested agent/strength FDA labeled for acute migraine AND
  • - Medication overuse headache ruled out
  • OR
  • D. Other diagnosis (non-migraine/cluster) with clinical benefit
  • AND
  • 3. No FDA labeled contraindications

Approval duration

Migraine prophylaxis: 6 months; Other indications: 12 months; Renewal: 12 months