Reyvow – NC Standard

Restricted Product(s)

• Reyvow™ (lasmiditan)

FDA Approved Use

• For the acute treatment of migraine with or without aura in adults.

Criteria for Approval of Restricted Product(s)

1. The patient is being treated for acute migraine with or without aura; AND 
2. The patient has tried and failed ONE unrestricted triptan product; OR 
   1. The patient has a clinical intolerance/contraindication to all unrestricted triptan products on the formulary that have not been tried; AND 
3. The patient will NOT be using the requested agent in combination with another acute migraine therapy (i.e., 5HT-1F, acute use CGRP, ergotamine, triptan); AND 
4. The patient has been evaluated for and does not have medication overuse headache (i.e., a chronic daily headache and a secondary disorder in which acute medications used excessively causes headache in a headache-prone patient); AND 
5. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.
   
   Duration of Approval: 365 days (1 year)

Continuation Coverage Criteria

1. The patient was approved through Blue Cross NC initial criteria for approval; OR 
2. The patient would have met criteria for approval at the time they started therapy; AND 
3. The patient continues to show acute migraine symptom relief from the use of the requested agent; AND 
4. The patient will NOT be using the requested agent in combination with another acute migraine therapy (i.e., 5HT-1F, acute use CGRP, ergotamine, triptan).
   
   Duration of Approval: 365 days (1 year)

Quantity Limit Exception Criteria

1. The patient has tried and failed at least two of the following abortive migraine therapy medication classes: 
   1. NSAIDS/COX-2 Inhibitor (Ex. ibuprofen, naproxen, diclofenac, celecoxib, etc.) 
   2. Acetaminophen (Tylenol) 
   3. Ergotamine-containing products (Ex. Cafergot, Ergomar, etc.); AND 
2. If the patient experiences > 4 migraine headaches per month, prophylactic therapy (Ex. amitriptyline, nortriptyline, topiramate, propranolol, divalproex) should have been given an adequate trial of at least 2 – 3 months; AND 
3. The possibility of medication-induced, rebound or chronic daily headache has been considered and ruled out; AND 
4. The quantity (dose) requested is for documented titration purposes at the initiation of therapy (authorization for a 90 day titration period); AND 
5. The prescribed dose cannot be achieved using a lesser quantity of a higher strength; AND 
6. The quantity (dose) requested does not exceed the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert; OR 
7. If the quantity (dose) requested exceeds the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert, then the prescriber must submit documentation in support of therapy with a higher dose for the intended diagnosis (submitted documentation may include medical records OR fax form which reflects medical record documentation that shows the length of time the requested dose has been used, and what other medications and doses have been tried and failed). 

References

All information referenced is from FDA package insert unless otherwise noted below.

Policy Implementation/Update Information

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q4 annually.

October 2024: Criteria change: Added requirement that Reyvow cannot be used in combination with another acute migraine therapy.
January 2022: Criteria update: Reduced required step through two triptan products to one triptan.
September 2020: Criteria update: Changed quantity limit on Reyvow to 8 tablets per 30 days.
Feb 2020: Original utilization management criteria issued.