Zavzpret — Blue Cross Blue Shield of Montana

Preferred products

• Aimovig
• Ajovy
• Emgality
• Nurtec ODT

Initial criteria

• ONE of the following: (A) The requested agent is being used for migraine prophylaxis AND BOTH of the following criteria are met: (1) ONE of the following: (A) The requested agent is eligible for continuation of therapy (prescriber states patient has been treated with requested agent within past 90 days and is at risk if therapy changed) OR (B) Diagnostic and labeling criteria — (A) Chronic migraine defined as ≥15 headache days/month for ≥3 months with ≥8 migraine days and agent/strength FDA-labeled for chronic migraine prophylaxis OR (B) Episodic migraine defined as 4–14 monthly migraine days and agent/strength FDA-labeled for episodic migraine prophylaxis) AND (2) ONE of the following: (A) Requested agent is preferred or stand-alone OR (B-I) Step therapy exception applies (see below).
• Step therapy exceptions for non-preferred agents—Allowed if ANY of the following: (A) Patient is currently stable on the requested agent; OR (B) Patient has tried and had inadequate response to ≥1 preferred agent for the requested indication; OR (C) Has intolerance/hypersensitivity to ≥1 preferred agent; OR (D) Has FDA labeled contraindication to ALL preferred agents; OR (E) Preferred agent discontinued due to lack of efficacy/effectiveness/diminished effect/adverse event; OR (F) Preferred agent expected to be ineffective or harmful based on patient or drug characteristics or prevents adherence/worsens comorbidity/reduces function; OR (G) Preferred agent not in patient’s best interest based on medical necessity; OR (H) Patient tried another drug of same pharmacologic class or mechanism as a preferred agent with lack of efficacy/effect/adverse event.
• Additional requirement: Medication overuse headache ruled out.
• Patient will NOT be using requested agent in combination with another prophylactic CGRP.
• OR (B) Requested agent used for episodic cluster headache AND ALL of the following: (1) ≥5 cluster headache attacks; (2) ≥2 cluster periods of 7–365 days; (3) Cluster periods separated by remission ≥3 months; (4) ONE of the following: (A) Cancer use exception as detailed OR (B) Patient has tried, had inadequate response, intolerance, or contraindication to ≥1 prerequisite agent (verapamil, melatonin, corticosteroids, topiramate, lithium); (5) Requested agent/strength FDA-labeled for episodic cluster headache; (6) Medication overuse headache ruled out.
• OR (C) Requested agent used for acute migraine treatment AND ALL of the following: (1) ONE of the following: (A) Cancer use exception as detailed OR (B) Patient has tried and had inadequate response or intolerance to ≥1 triptan OR (C) Has an FDA labeled contraindication to ALL triptans; (2) Not used in combination with another acute-use therapy (5HT-1F, acute-use CGRP, ergotamine); (3) ONE of following: (A) Requested agent is preferred or stand-alone OR (B-I) Step therapy exceptions as above; (4) Agent/strength FDA-labeled for acute migraine; (5) Medication overuse headache ruled out.
• OR (D) Another FDA labeled indication for the requested agent and route of administration; OR (E) Another indication supported in compendia (AHFS or DrugDex 1, 2a, or 2b) with age consistent with labeling or supported by evidence; AND patient has no FDA labeled contraindications.

Reauthorization criteria

• Same as initial criteria (continuation defined as prescriber attesting patient has been treated with and is stable on requested agent within prior 90 days).

Approval duration

Migraine prophylaxis - 6 months; all other indications - 12 months (BCBSIL 12 months)