- Step Therapy: Acute Migraine, Migraine:
ST Multiple Generics
Migraine Prevention:
ST Generic and Brand
- 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)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Migraine Frequency: N/A
Is supporting documentation required for initial approval: No
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
Migraine Prevention:
Age Requirement: >= 18
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Specialist Type(s): 1 of Headache Specialist;Neurologist;Pain Management Specialist
- Prior Authorization: Acute Migraine, Migraine:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Migraine Prevention:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 3 Month(s)
- Quantity Limit: limit maximum 8 EA PER fill retail
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