Target Agent(s) — Blue Cross Blue Shield of Texas

acute migraine treatment

Initial criteria

The patient’s age is within FDA labeling for the requested indication for the requested agent OR there is support for using the requested agent for the patient’s age for the requested indication
The patient does NOT have any FDA labeled contraindications to the requested agent
If the request is for BCBS NM Fully Insured or NM HIM member: requested indication is a rare disease AND ONE of the following: (1) patient has another FDA labeled indication for the requested agent and route of administration OR (2) patient has another indication supported in compendia for the requested agent and route of administration
OR if member resides in Ohio and plan is Fully Insured or HIM Shop (SG): patient does not have any FDA labeled contraindications AND ONE of the following: (1) patient has another FDA labeled indication for the requested agent and route of administration OR (2) patient has another indication supported in compendia for the requested agent and route of administration OR (3) prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use as generally safe and effective

The patient has been approved for the requested agent previously through the Plan’s Prior Authorization process
ONE of the following: (A) requested agent is used for acute migraine treatment AND (1) patient has had clinical benefit with the requested agent AND (2) ONE of: (A) requested agent is NOT REYVOW OR (B) requested agent is REYVOW AND patient will NOT be using the requested agent in combination with another acute migraine therapy (5HT-1F, acute use CGRP, ergotamine, triptan) AND (3) medication overuse headache has been ruled out; OR (B) patient has diagnosis other than acute migraine treatment AND has had clinical benefit with the requested agent
The patient does NOT have any FDA labeled contraindications to the requested agent

12 months