- Acute Migraine:
Age Requirement: >= 18
Duration: 12 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: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: No
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: 3 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: 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 0.14 EA PER 1 day(s)
- Step Therapy: ST Multiple Brands
- Prior Authorization: Acute Migraine:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Migraine:
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
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