Initial Evaluation
Dihydroergotamine mesylate nasal spray will be approved when ALL of the following are met:
- The requested medication will be used for the treatment of acute migraine with or without aura AND
- ONE of the following:
- The patient has tried and had an inadequate response to TWO triptan medications with differing active ingredients (e.g., sumatriptan, rizatriptan) OR
- The patient has an intolerance or hypersensitivity to TWO triptan medications with differing active ingredients OR
- The patient has an FDA labeled contraindication to TWO triptan medications with differing active ingredients AND
- The patient will NOT be using the requested medication in combination with another acute migraine medication (e.g., triptan, 5HT-1F, acute CGRP) AND
- ONE of the following:
- The requested quantity (dose) does NOT exceed the program quantity limit OR
- BOTH of the following:
- The requested quantity (dose) is greater than the program quantity limit AND
- The prescriber has provided information in support of therapy with a higher dose for the requested indication
Length of Approval: 12 months
Renewal Evaluation
Dihydroergotamine mesylate nasal spray will be approved when ALL of the following are met:
- The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria AND
- The requested medication will be used for the treatment of acute migraine with or without aura AND
- The patient has had clinical benefit with the requested medication AND
- The patient will NOT be using the requested medication in combination with another acute migraine medication (e.g., triptan, 5HT-1F, acute CGRP) AND
- ONE of the following:
- The requested quantity (dose) does NOT exceed the program quantity limit OR
- BOTH of the following:
- The requested quantity (dose) is greater than the program quantity limit AND
- The prescriber has provided information in support of therapy with a higher dose for the requested indication
Length of Approval: 12 months
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
Information in other languages: Español 中文 Tiếng Việt 한국어 Français العَرَبِيَّة Hmoob ру́сский Tagalog ગુજરાતી ភាសាខ្មែរ Deutsch हिन्दी ລາວ 日本語
© 2026 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.