Migergot (ergotamine tartrate and caffeine) suppository — Highmark

Preferred products

• sumatriptan injection
• sumatriptan nasal spray
• plan-preferred generic zolmitriptan nasal spray

Initial criteria

• For aborting vascular headache: Member uses Migergot to abort vascular headache (ICD-10: G44.1, G43) AND prescriber attests member experiences significant nausea and vomiting and requires a non-oral route of administration AND member has experienced therapeutic failure, contraindication, or intolerance to one of the following plan preferred generic products: sumatriptan injection OR sumatriptan nasal spray AND member has experienced therapeutic failure, contraindication, or intolerance to plan-preferred generic zolmitriptan nasal spray
• OR For preventing vascular headache: Member uses Migergot to prevent vascular headache (ICD-10: G44.1, G43) AND prescriber attests member experiences significant nausea and vomiting and requires a non-oral route of administration

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