- Quantity Limit: 2 injections / 25 days
- Step Therapy: ST Multiple Generics
- PA applies if Step is Not Met
- Migraine:
Age Requirement: >= 18
Duration: 6 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 Frequency: 4 per month
Is supporting documentation required for initial approval: Yes
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: No
Reauthorization Criteria Includes 7 Day100 Hour Reduction Language: No
ICHD2ICHD3 Language Included in Policy: chronic migraines occurring at least 15 days in a single month, for at least 3 months
Retreatment Language Included in Policy: N/A
Policy Contains ICHD2 or ICHD3 Language: ICHD 3 criteria exist
Migraine Prevention: Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Specialist Type(s): 1 of Headache Specialist;Neurologist;Pain Management Specialist
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