Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsAdvanced Health Butalbital Prior Auth | OpenPayer
    Ask Trek AI about this page
    CurrentAdvanced HealthPolicy N/A

    Butalbital-Containing Products Drug Use Criteria

    Customize your policy alerts

    Sign up for all advancedhealth policy alerts

    Know when advancedhealth releases new policies or updates existing guidance.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs prior authorization and coverage criteria for butalbital-containing products used by Oregon Health Plan members for headaches. It applies to requests for acute treatment of chronic migraine, tension-type headache, or acute migraine, with age, pregnancy, medication-overuse, severity, and prior-treatment requirements.

    Policy Summary
    PayerAdvanced Health
    PolicyButalbital-Containing Products Drug Use Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit prior authorization requests with the covered indication, required alternative-therapy history, medication-overuse assessment, and applicable pregnancy documentation.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    18 tablets/3 daysQuantity limit
    6 doses/dayMaximum dosing
    9 monthsPregnancy approval
    12 monthsStandard approval

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ≤20 years
    Age threshold

    Coverage Criteria

    Off-label use of medication is not a covered benefit under the Oregon Health Plan.

    The Oregon Health Plan does not pay for treatment of a condition designated below the line.

    For non-headache indications, members age 20 or younger require documentation that the condition is sufficiently severe to impact health, including quality of life, function, growth, development, school participation, or activities of daily living. If sufficient severity is not documented, send the request to MD review to determine medical appropriateness and/or medical necessity.

    Provider Requirements and Decision Outcomes

    Prior Authorization

    Prior Authorization and Clinical Pathway

    Prior authorization is required for butalbital-containing products. The request must be for acute treatment of chronic migraine or tension-type headache; otherwise, members age 20 or younger must have documentation that the condition is sufficiently severe to affect health, and members older than 20 with a noncovered indication do not meet criteria. The review pathway also evaluates pregnancy, medication overuse, and required alternative-therapy trials.

    Step Therapy

    Tension-Type Headache Alternatives

    For tension-type headache, document that the member has trialed and failed, or has contraindications to, all required alternatives: an NSAID, acetaminophen, and a caffeine-containing combination analgesic.

    • NSAID: ibuprofen, naproxen, or aspirin.
    • Acetaminophen.
    • Caffeine combination: caffeine with an NSAID, caffeine with acetaminophen, or acetaminophen/aspirin/caffeine.
    Step Therapy

    Acute Migraine Alternatives

    For acute migraine, document that the member has trialed and failed, or has contraindications to, all of the required alternatives: at least one NSAID, acetaminophen, and at least one triptan.

    • At least one NSAID.
    • Acetaminophen.
    • At least one triptan.
    Step Therapy

    Pregnancy Acetaminophen Step

    For a pregnant member, acetaminophen must be trialed and failed before butalbital combination therapy is considered. The documented trial may be up to 1,000 mg per day.

    Documentation Required

    Diagnosis and Clinical Impact

    Document the member’s diagnosis and the covered treatment indication, including whether the request is for acute treatment of chronic migraine or tension-type headache. If the indication is not one of these conditions, document the condition’s clinical impact when required, such as effects on quality of life, function, growth, development, school participation, or activities of daily living.

    Documentation Required

    Pregnancy Documentation

    For pregnant members, submit documentation that acetaminophen was trialed at up to 1,000 mg per day and failed before butalbital therapy is initiated.

    Documentation Required

    Medication-Overuse Assessment

    Document that the headaches are not due to medication overuse. The plan may review fill history and notify the provider if medications associated with medication-overuse headache are being filled consistently.

    • Potentially relevant medications include aspirin, acetaminophen, NSAIDs, and opioids.
    Documentation Required

    Required Alternative Therapy History

    Submit documentation of prior trials, failures, or contraindications for the required alternatives applicable to the diagnosis. The history must identify which therapies were tried and failed or why they are contraindicated.

    • Tension-type headache: an NSAID, acetaminophen, and a caffeine-containing combination analgesic.
    • Acute migraine: at least one NSAID, acetaminophen, and at least one triptan.
    Denial Risk

    Noncovered Indication or Age

    Deny the request as not meeting criteria or below the line when a member older than 20 years is being treated for a noncovered indication. Off-label use is not a covered benefit under the Oregon Health Plan, and the plan does not pay for treatment of a below-the-line condition.

    Denial Risk

    Insufficient Severity Documentation

    For a member age 20 or younger with a non-headache indication, insufficient documentation that the condition significantly impacts the member’s health does not establish coverage. Send the request to physician review to determine medical appropriateness and/or medical necessity.

    • Examples of impact include effects on quality of life, function, growth, development, school participation, or activities of daily living.
    Denial Risk

    No Acetaminophen Trial in Pregnancy

    For a pregnant member, deny the request as not meeting criteria until acetaminophen, up to 1,000 mg per day, has been trialed and failed before moving to butalbital combination products.

    Denial Risk

    Medication-Overuse Headache Not Excluded

    Deny the request as not meeting criteria when documentation does not establish that the headaches are not due to medication overuse. Request the required documentation and consider reviewing fill history for consistent use of medications associated with medication-overuse headache.

    Denial Risk

    Tension-Headache Prerequisites Incomplete

    For tension-type headache, deny the request as not meeting criteria when the member has not trialed and failed, or does not have contraindications to, every required alternative.

    • Required prerequisites: an NSAID; acetaminophen; and a caffeine-containing combination analgesic, including caffeine with an NSAID, caffeine with acetaminophen, or acetaminophen/aspirin/caffeine.
    • State which prerequisite(s) have not been met.
    Denial Risk

    Migraine Prerequisites Incomplete

    For acute migraine, deny the request as not meeting criteria when the member has not trialed and failed, or does not have contraindications to, every required alternative.

    • Required prerequisites: at least one NSAID, acetaminophen, and at least one triptan.
    • State which prerequisite(s) have not been met.

    Medication Background

    Butalbital-containing products combine a barbiturate with analgesic ingredients such as acetaminophen or aspirin. Some products also contain caffeine and/or codeine.

    Policy Definitions

    Medication overuse
    DefinitionHeadache caused or worsened by frequent or consistent use of medications.
    Examples of associated medicationsAspirin, acetaminophen, NSAIDs, opioids, and other headache medicines.
    Coverage assessmentRequests must document that the headaches are not due to medication overuse.
    Off-label use
    DefinitionUse of a medication for a condition or indication outside the covered criteria.
    Coverage treatmentOff-label use of the medication is not a covered benefit under the Oregon Health Plan.
    Related noncovered treatment

    Initial Request Requirements

    Required Step Therapy

    StepRequired alternativesRequirement
    1NSAIDs (ibuprofen, naproxen, or aspirin); acetaminophen; and caffeine-containing combination analgesics (caffeine with an NSAID or acetaminophen) or acetaminophen/aspirin/caffeineBefore butalbital therapy for tension-type headache, the member must have trialed and failed or have contraindications to all listed alternatives.
    StepRequired alternativesRequirement
    1At least one NSAID; acetaminophen; and at least one triptanBefore butalbital therapy for acute migraine, the member must have trialed and failed or have contraindications to all listed alternatives.
    StepRequired alternativeRequirement
    1Acetaminophen, up to 1,000 mg per dayDuring pregnancy, the member must trial and fail acetaminophen before butalbital treatment.

    Quantity and Duration Limits

    Pregnant members
    Maximum quantity18 tablets per 3 days.
    Quantity interval18 tablets every 30 days.
    Maximum approval durationUp to 9 months after a failed trial of acetaminophen up to 1,000 mg per day.
    Qualifying tension-type headache or acute migraine
    Maximum quantity18 tablets per 3 days.
    Maximum dosing frequencyUp to 6 doses per day.
    Quantity interval and approval duration18 tablets every 30 days; approval may be granted for up to 12 months.
    Policy Summary
    PayerAdvanced Health
    PolicyButalbital-Containing Products Drug Use Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit prior authorization requests with the covered indication, required alternative-therapy history, medication-overuse assessment, and applicable pregnancy documentation.
    SourceLink
    On This Page
    Coverage CriteriaProvider Requirements and Decision OutcomesMedication BackgroundPolicy DefinitionsInitial Request RequirementsRequired Step TherapyQuantity and Duration Limits
    Treatment of a condition designated below the line is not paid by the Oregon Health Plan.