Skip to content
The Policy VaultThe Policy Vault

Reyvow (lasmiditan) — United Healthcare

acute treatment of migraine

Preferred products

  • almotriptan (Axert)
  • eletriptan (Relpax)
  • frovatriptan (Frova)
  • naratriptan (Amerge)
  • rizatriptan (Maxalt/Maxalt MLT)
  • sumatriptan (Imitrex)
  • zolmitriptan (Zomig/Zomig-ZMT)
  • Nurtec ODT
  • Ubrelvy

Initial criteria

  • Used for acute treatment of migraine
  • Patient is age ≥ 18 years
  • History of a therapeutic failure (after at least 3 migraine episodes and a minimum of a 30-day trial), contraindication, or intolerance to BOTH of the following (document name and date tried):
  • 1) Two of the following triptans: almotriptan (Axert), eletriptan (Relpax), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt/Maxalt MLT), sumatriptan (Imitrex), zolmitriptan (Zomig/Zomig-ZMT)
  • 2) Both of the following: Nurtec ODT, Ubrelvy
  • Prescriber attests to BOTH of the following:
  • 1) Patient informed that Reyvow may cause significant CNS impairment impacting ability to drive or operate machinery for 8 hours after each dose
  • 2) If used concurrently with a benzodiazepine or other CNS depressant, prescriber has assessed increased risk for sedation or cognitive/neuropsychiatric adverse events
  • One of the following:
  • 1) Patient is currently treated with one of the following prophylactic therapies: beta-blocker (atenolol, metoprolol, nadolol, propranolol, or timolol), candesartan (Atacand), calcitonin gene-related peptide receptor antagonist or inhibitor for preventive treatment of migraine [Aimovig (erenumab), Ajovy (fremanezumab), Emgality (galcanezumab), Qulipta, Vyepti (eptinezumabjjmr)], divalproex sodium (Depakote/Depakote ER), onabotulinumtoxinA (Botox), serotonin-norepinephrine reuptake inhibitor [duloxetine (Cymbalta), venlafaxine (Effexor/Effexor XR)], topiramate (Topamax), tricyclic antidepressant [amitriptyline (Elavil), nortriptyline (Pamelor)]
  • OR Patient has < 4 migraine days per month
  • OR Patient has ≥ 4 migraine days per month and has contraindication or intolerance to one of the following prophylactic therapies: beta-blocker (atenolol, metoprolol, nadolol, propranolol, or timolol), candesartan (Atacand), calcitonin gene-related peptide receptor antagonist or inhibitor for preventive treatment of migraine [Aimovig (erenumab), Ajovy (fremanezumab), Emgality (galcanezumab), Qulipta, Vyepti (eptinezumabjjmr)], divalproex sodium (Depakote/Depakote ER), onabotulinumtoxinA (Botox), serotonin-norepinephrine reuptake inhibitor [duloxetine (Cymbalta), venlafaxine (Effexor/Effexor XR)], topiramate (Topamax), tricyclic antidepressant [amitriptyline (Elavil), nortriptyline (Pamelor)]

Reauthorization criteria

  • Documentation of positive clinical response to therapy

Approval duration

12 months