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Title: |
| Migraine Medications Quantity Limit Override Criteria |
Program Objectives: |
| The intent of the migraine agents quantity limit is to encourage appropriate prescribing quantities as recommended by Food and Drug Administration (FDA) approved product labeling. Oral, nasal (Imitrex, Zomig), and injectable (Imitrex) dosage forms are included. The intent of the post-quantity limit criteria for the migraine agents is to allow for review of requests for quantities exceeding the determined limit while ensuring that patients and physicians address the current guidelines for the prevention and treatment of migraine and/or cluster headache. |
Recommended Quantity Limits: |
|
| Medication |
Quantity Allowed per 30 days |
| Amerge® (naratriptan) |
18 tablets |
| Axert® (almotriptan) |
12 tablets |
| Frova® (frovatriptan) |
12 tablets |
| Imitrex® (sumatriptan) |
18 tablets |
| Imitrex® nasal (sumatriptan) |
6 units / 1 box |
| Imitrex® syringe (sumatriptan) |
4 mL / 8 doses |
| Maxalt®, Maxalt-MLT® (rizatriptan) |
12 tablets |
| Relpax® (eletriptan) |
12 tablets |
| TreximetTM (sumatriptan/naproxen) |
18 tablets |
| Zomig ® nasal (zolmitriptan) |
12 units / 2 boxes |
| Zomig ® Zomig ZMT® (zolmitriptan) |
12 tablets |
|
Effective Date: |
| 06/08 for Oklahoma |
Prior Authorization Criteria For Approval: |
Amerge®, Axert®, Frova®, Imitex®, Maxalt®, Maxalt-MLT®, Relpax®, TreximentTM, Zomig®, Zomig ZMT®
Initial and Renewal Evaluation
1. Is the quantity requested greater than the set limit?
If yes, continue to 2.
If no, review is not applicable. Claim will adjudicate.
2. Does the patient have the diagnosis of migraine headache, cluster headache, or other severe headache?
If yes, continue to 3.
If no, deny.
3. Is the patient currently prescribed prophylactic migraine medication?
If yes, continue to 5.
If no, continue to 4.
4. Has the physician determined that the patient has an allergy, contraindication, intolerance, or treatment failure to prophylactic migraine therapy or does the patient refuse prophylactic therapy?
If yes, continue to 5.
If no, deny.
5. Has the physician evaluated the patient for medication overuse headache?
If yes, continue to 6.
If no, deny.
6. Is the patient taking this medication in combination with another triptan (e.g., Amerge, Axert, Imitrex, Frova, Maxalt, Maxalt-MLT, Relpax, Zomig, Zomig-ZMT) or an ergotamine (e.g., Migranal®, DHE®, Cafergot®)? (Patient should not take together due to possibility of increased blood pressure effect.)
If yes, deny.
If no, approve the quantity requested (may include all dosage forms) for 12 months. |
| CPT® only copyright 2003 American Medical Association. All Rights Reserved. | |
