Nurtec ODT — Highmark

Initial criteria

• age ≥ 18 years
• diagnosis of migraine (ICD-10: G43), classified as episodic migraine defined as 4 to 14 headache days per month
• prescriber attests to: baseline average monthly migraine days AND headaches not caused by medication overuse or lifestyle factors AND therapeutic failure or intolerance to one agent from two different plan-preferred prophylactic migraine medication classes or all are contraindicated (alpha-agonists; ACE inhibitors or ARBs; anti-epileptic drugs; beta-blockers; calcium channel blockers; SNRIs; tricyclic antidepressants)
• if using two chemically distinct CGRP inhibitors in combination for preventive and acute use, prescriber attests that benefits outweigh risks of concurrent use

Reauthorization criteria

• The prescriber attests that the member has experienced a reduction in one of the following: reduction in the number of migraine days per month by at least 50% from baseline OR a reduction in migraine days per month by at least 4 days from baseline.
• Subsequent reauthorizations are subject to sustained improvements noted above.

Approval duration

initial 6 months (12 months for Delaware), reauth 12 months