- Prior Authorization: Documented Diagnosis: Yes
- Acute Migraine:
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Appropriate Specialist
Reauthorization Required: No
Duration of Reauthorization: N/A
Migraine: Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Appropriate Specialist
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
- Step Therapy: ST Multiple Generics
- Quantity Limit: limit maximum 0.27 EA PER 1 day(s)
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