| Anthem Blue Cross (HMO, PPO, EPO) |
| Migranal (dihydroergotamine) |
| Drugs for the Nervous System : Drugs for Migraine Headaches |
- Acute Migraine:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Migraine:
Duration: 12 Month(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
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
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
- Quantity Limit: limit maximum 8 mL PER 28 day(s)
- ST Applies
- Prior Authorization: Acute Migraine:
Documented Diagnosis: Yes
Duration: 1 year(s)
Migraine:
Duration: 12 Month(s)
- Step Therapy: Acute Migraine:
ST Multiple Generics
Migraine:
ST Single Generic
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;
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