Ubrelvy — Highmark

Initial criteria

• age ≥ 18 years
• diagnosis of migraine (ICD-10: G43), classified as acute migraine headaches with or without aura
• therapeutic failure, contraindication, or intolerance to two of the following: generic oral sumatriptan, generic oral rizatriptan, or generic oral zolmitriptan
• 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 positive clinical response to therapy.

Approval duration

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