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CGRP targeted agents — Blue Cross Blue Shield of Texas

migraine prophylaxis

Initial criteria

  • The patient has another FDA labeled indication for the requested agent and route of administration OR
  • The patient has another indication that is supported in compendia for the requested agent and route of administration OR
  • The prescriber has submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective (randomized, double-blind, placebo-controlled trials; case studies are not acceptable)

Reauthorization criteria

  • The patient has been approved for the requested agent previously through the plan’s Prior Authorization process AND
  • ONE of the following:
  • A. BOTH of the following:
  • 1. ONE of the following:
  • A. The requested agent is being used for migraine prophylaxis AND ALL of the following:
  • • The patient has had clinical benefit with the requested agent AND
  • • The patient will NOT be using the requested agent in combination with another prophylactic use CGRP AND
  • • ONE of the following:
  • A. BOTH of the following:
  • • The patient has a diagnosis of chronic migraine (≥15 headache days per month of migraine-like or tension-like headache for a minimum of 3 months prior to migraine prevention therapy) AND
  • • The requested agent and strength are FDA labeled for chronic migraine OR
  • B. BOTH of the following:
  • • The patient has a diagnosis of episodic migraine (4–14 monthly migraine days prior to migraine prevention therapy) AND
  • • The requested agent and strength are FDA labeled for episodic migraine OR
  • B. The requested agent is being used for episodic cluster headache treatment AND BOTH of the following:
  • • The patient has had clinical benefit with the requested agent AND
  • • The requested agent and strength are FDA labeled for episodic cluster headache treatment OR
  • C. The requested agent is being used for acute migraine treatment AND ALL of the following:
  • • The patient has had clinical benefit with the requested agent 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) for the requested indication AND
  • • The requested agent and strength are FDA labeled for acute migraine treatment AND
  • Medication overuse headache has been ruled out OR
  • B. The patient has a diagnosis other than migraine prophylaxis, episodic cluster headache treatment, or acute migraine treatment AND has had clinical benefit with the requested agent AND
  • The patient does not have any FDA labeled contraindications to the requested agent

Approval duration

12 months