Western Health Advantage - All plan years
Kalbitor (ecallantide)
Drugs for the Heart : Drugs for the Heart
  • Step Therapy: ST_APPLIES
  • Step Therapy: Derm: Acne Vulgaris:
    ST Multiple Generics

  • Acute Migraine:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Headache Specialist;Neurologist;Pain Management Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Migraine:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Headache Specialist;Neurologist;Pain Management Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Migraine Frequency: N/A
    Is supporting documentation required for initial approval: Yes
    Is supporting documentation required for re-approval: No
    Policy Contains Verbiage for Botulinum Interchangeability: No
    Diagnosis of Chronic Migraine Required: No
    Required Decrease in Duration of Chronic Migraine for Reauthorization: N/A
    Provider Responsibility Language Referenced in Policy: No
    Dose Conversion Language Included in Policy: No
    Reauthorization Criteria Includes 50% Reduction Language: No
    Reauthorization Criteria Includes 7 Day100 Hour Reduction Language: No
    Retreatment Language Included in Policy: N/A
    Policy Contains ICHD2 or ICHD3 Language: No ICHD2 or ICHD3 criteria exist

  • Quantity Limit: limit maximum 10 EA PER 1 day(s)