Skip to content
The Policy VaultThe Policy Vault

Zavzpret — Blue Cross Blue Shield of Oklahoma

Migraine prophylaxis (chronic or episodic)

Preferred products

  • Aimovig
  • Ajovy
  • Emgality
  • Nurtec ODT

Initial criteria

  • 1. One of the following applies:
  • A. Migraine prophylaxis:
  • - ONE of the following:
  • • Patient eligible for continuation of therapy (treated with requested agent within past 90 days, not samples, and at risk if changed).
  • • OR patient meets BOTH: chronic migraine (≥15 headache days/month for ≥3 months with ≥8 migraine days/month) OR episodic migraine (4-14 monthly migraine days for ≥3 months) AND requested agent and strength are FDA labeled for migraine prophylaxis.
  • - ONE of the following:
  • • Requested agent is preferred or stand-alone agent, OR
  • • Patient meets one of: stage IV metastatic cancer use per FDA/best-practice support; currently stable on requested agent; tried and failed/intolerant to ≥1 preferred agent; contraindicated to all preferred agents; discontinued preferred agent due to inefficacy or adverse event; preferred agent expected to be ineffective or contraindicated based on clinical characteristics; preferred agent not in best interest due to medical necessity; tried another class-related drug and discontinued due to lack of efficacy or adverse event.
  • - Medication overuse headache ruled out.
  • - Patient NOT using requested agent in combination with another prophylactic CGRP.
  • B. Episodic cluster headache:
  • - ≥5 cluster headache attacks.
  • - ≥2 cluster periods lasting 7–365 days separated by pain-free remission ≥3 months.
  • - ONE of the following: stage IV metastatic cancer criteria as above, OR tried/failed/intolerant/contraindicated to ≥1 prerequisite agent (verapamil, melatonin, corticosteroids, topiramate, lithium).
  • - Requested agent and strength FDA labeled for episodic cluster headache.
  • - Medication overuse headache ruled out.
  • C. Acute migraine treatment:
  • - ONE of the following: stage IV metastatic cancer criteria as above, OR tried/failed/intolerant/contraindicated to ≥1 triptan agent.
  • - Patient NOT using requested agent with another acute migraine therapy (5HT-1F, acute use CGRP, ergotamine).
  • - ONE of the following: requested agent is preferred/stand-alone or meets cancer-related or stability/failure/preference criteria as above.
  • - Requested agent and strength FDA labeled for acute migraine treatment.
  • - Medication overuse headache ruled out.
  • D. Patient may have another FDA labeled or compendia-supported indication with age within FDA labeling or supported for use.
  • - Patient does not have any FDA labeled contraindications to requested agent.

Approval duration

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