- Quantity Limit: 8 tablets per 30 day(s).
- PA Applies
- Acute Migraine:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Migraine:
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
Migraine Frequency: 4 per month
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: Unspecified
Provider Responsibility Language Referenced in Policy: No
Dose Conversion Language Included in Policy: No
Reauthorization Criteria Includes 50% Reduction Language: Yes
Reauthorization Criteria Includes 7 Day100 Hour Reduction Language: No
ICHD2ICHD3 Language Included in Policy: 2 of at least 15 headache days per month;chronic migraines occurring at least 15 days in a single month, for at least 3 months
Retreatment Language Included in Policy: N/A
Policy Contains ICHD2 or ICHD3 Language: ICHD 3 criteria exist
Migraine Prevention:
Duration: 3 Month(s)
Documented Diagnosis: Yes
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;- Step Therapy: ST Multiple Generics
- Prior Authorization: Acute Migraine:
Documented Diagnosis: Yes
Duration: 1 year(s)
Migraine:
Documented Diagnosis: Yes
Duration: 3 Month(s)
Reauthorization Required: Yes
Migraine Prevention:
Documented Diagnosis: Yes
Duration: 3 Month(s)
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