| Anthem Blue Cross (HMO, PPO, EPO) |
| Qulipta (atogepant) |
| Drugs for the Nervous System : Drugs for Migraine Headaches |
- Step Therapy: ST Generic and Brand
- Quantity Limit: 1 tablet per 1 day(s).
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;- PA Applies
- 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
Retreatment Language Included in Policy: N/A
Policy Contains ICHD2 or ICHD3 Language: No ICHD2 or ICHD3 criteria exist
Migraine Prevention:
Duration: 3 Month(s)
Documented Diagnosis: Yes
- Prior Authorization: Migraine:
Documented Diagnosis: Yes
Duration: 3 Month(s)
Reauthorization Required: Yes
Migraine Prevention:
Documented Diagnosis: Yes
Duration: 3 Month(s)
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