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Zavzpret — Blue Cross Blue Shield of Texas

Episodic cluster headache

Preferred products

  • Aimovig
  • Ajovy
  • Emgality
  • Nurtec ODT

Initial criteria

  • ONE of the following:
  • A. Migraine prophylaxis AND BOTH of the following:
  • 1. ONE of the following:
  • A. Patient eligible for continuation of therapy – treated with requested agent within past 90 days (samples not approvable) and at risk if therapy changed OR
  • B. Patient meets chronic or episodic migraine definitions:
  • • Chronic migraine: ≥15 headache days/month for ≥3 months including ≥8 migraine days/month and requested agent labeled for chronic migraine prophylaxis OR
  • • Episodic migraine: 4–14 monthly migraine days and requested agent labeled for episodic prophylaxis
  • 2. ONE of the following:
  • A. Requested agent is a preferred or stand-alone agent for indication OR
  • B. ONE of the following applies:
  • • Patient has stage 4 advanced metastatic cancer and use is to treat the cancer or an associated condition and consistent with best practices and FDA approved OR
  • • Patient is stable on requested agent OR
  • • Patient has tried and had inadequate response to ONE preferred agent for indication OR intolerance/hypersensitivity to ONE preferred agent OR FDA labeled contraindication to ALL preferred agents OR ONE preferred agent discontinued due to lack of efficacy or adverse event OR expected to be ineffective, harmful, or not in best interest based on medical necessity OR patient tried another agent in same class with failure or adverse event
  • 3. Medication overuse headache ruled out AND
  • 4. Requested agent not used in combination with another prophylactic CGRP agent
  • B. Episodic cluster headache AND ALL of the following:
  • 1. ≥5 cluster headache attacks
  • 2. ≥2 cluster periods lasting 7–365 days
  • 3. Cluster periods separated by ≥3-month pain-free remission
  • 4. ONE of: stage 4 metastatic cancer considerations OR inadequate response/intolerance/contraindication to one prerequisite agent (verapamil, melatonin, corticosteroids, topiramate, lithium)
  • 5. Requested agent labeled for episodic cluster headache
  • 6. Medication overuse headache ruled out
  • C. Acute migraine treatment AND ALL of the following:
  • 1. ONE of: stage 4 metastatic cancer criteria OR inadequate response/intolerance/contraindication to one triptan
  • 2. Not used in combination with another acute migraine therapy (5HT-1F, acute CGRP, ergotamine)
  • 3. ONE of: requested agent is preferred or stand-alone OR stage 4 metastatic cancer criteria OR stable on agent OR inadequate response/intolerance/contraindication to one preferred agent or discontinued/lack of efficacy condition as defined above
  • 4. Requested agent labeled for acute migraine treatment
  • 5. Medication overuse headache ruled out
  • D. Another FDA labeled indication or compendia-supported indication (AHFS or DrugDex 1,2a,2b) with age consistent with labeling or supported and no labeled contraindications

Approval duration

6–12 months (6 months for migraine prophylaxis except BCBSIL: 12 months; all others 12 months for other indications)