Ubrelvy — Medical Mutual

Initial criteria

• Patient has a diagnosis of migraine, with or without aura, according to the International Classification of Headache Disorders (ICHD-3); AND
• Patient age ≥ 18 years; AND
• Patient has tried at least one triptan therapy OR Patient has a contraindication to triptan therapy according to the prescriber

Reauthorization criteria

• Clinical response to therapy is required for continuation of therapy

Approval duration

initial: 3 months; reauth: 1 year