Qulipta — Highmark
chronic migraine
Initial criteria
- age ≥ 18 years
- diagnosis of migraine (ICD-10: G43) classified as either episodic migraine (4–14 headache days per month) OR chronic migraine (≥15 headache days per month of which ≥8 are migraine days)
- prescriber attests to baseline average monthly migraine days
- headaches are not caused by medication rebound or overutilization or due to lifestyle factors
- therapeutic failure or intolerance to one agent from two different plan-preferred prophylactic migraine medication classes OR all are contraindicated (from: alpha-agonists, ACE inhibitors/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 benefits outweigh risks
Reauthorization criteria
- prescriber attests to reduction in one of the following: reduction in migraine days per month by ≥50% from baseline OR reduction in migraine days per month by ≥4 days (episodic) OR ≥5 days (chronic)
- subsequent reauthorizations subject to sustained improvements