Dihydroergotamine injection — Highmark

Preferred products

• generic sumatriptan injection

Initial criteria

• Diagnosis of acute migraine headaches with or without aura (ICD-10: G43) AND prescriber attests member experiences significant nausea and vomiting and requires a non-oral route of administration OR diagnosis of cluster headache (ICD-10: G44.00, G44.01, G44.02)
• Member has experienced therapeutic failure, contraindication, or intolerance to generic sumatriptan injection

Reauthorization criteria

• Prescriber attests that the member has experienced positive clinical response to therapy
• If request is for a brand product with a generic equivalent, member has experienced therapeutic failure or intolerance to the generic equivalent product

Approval duration

12 months