| Anthem Blue Cross (HMO, PPO, EPO) |
| Zomig (zolmitriptan) |
| Drugs for the Nervous System : Drugs for Migraine Headaches |
- Step Therapy: Migraine:
ST Multiple Generics
- Prior Authorization: Migraine:
Duration: 1 year(s)
- Quantity Limit: 9 tablets per 30 day(s).
- Migraine:
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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
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