Reyvow — Medical Mutual

Initial criteria

• Patient has a diagnosis of migraine, with or without aura, according to the International Classification of Headache Disorders (ICHD-3)
• Patient age ≥ 18 years
• Requested medication is prescribed by a neurologist, pain specialist, ophthalmologist, or a physician certified in headache medicine
• Provider has ruled out medication overuse as a possible cause of migraine
• Severity of the patient’s migraine is classified as moderate or severe
• Patient agrees to not engage in potentially hazardous activities requiring complete alertness (i.e. driving or operating heavy machinery) for at least 8 hours after each dose of Reyvow
• Patient meets one of the following criteria: (i) Patient has trialed TWO triptan therapies with little to no relief of moderate/severe migraine symptoms OR (ii) Patient has a contraindication to triptan therapy

Reauthorization criteria

• Continuation of therapy may be approved if patient continues to meet initial criteria

Approval duration

Initial: 3 months; Reauth: 12 months