Trudhesa — Blue Cross Blue Shield of Oklahoma
other indication that is supported in compendia for the requested agent and route of administration
Preferred products
- Any triptan agent
- triptan combination
Initial criteria
- Requested agent is being used for acute migraine treatment AND ALL of the following:
- • ONE of the following:
- – Patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
- – Patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes required] AND use of the requested agent is consistent with best practices for such cancer and supported by evidence-based literature and FDA approved, OR
- – Patient has tried and had an inadequate response to ONE prerequisite agent OR has intolerance or hypersensitivity to ONE prerequisite agent OR has an FDA labeled contraindication to ALL prerequisite agents
- • If the requested agent is REYVOW, patient will NOT be using another acute migraine therapy (5HT-1F, acute use CGRP, ergotamine, triptan)
- • Medication overuse headache has been ruled out
- OR patient has another FDA labeled indication for the requested agent and route of administration
- OR patient has another indication supported in compendia for the requested agent and route of administration