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    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsFlorida AHCA Butalbital Prior Auth | OpenPayer
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    CurrentAgency for Health Care AdministrationPolicy N/A

    Butalbital-Containing Products

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    This policy governs prior authorization requests for quantities of butalbital-containing products that exceed the existing quantity limitation. It applies to providers requesting coverage for patients with chronic tension-type or migraine headaches who meet specified specialty consultation and treatment-failure criteria.

    Policy Summary
    PayerAgency for Health Care Administration
    PolicyButalbital-Containing Products
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit prior authorization with progress notes documenting chronic attacks, specialist involvement, and the required treatment failures.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    120 tabs/caps or 180 mLMaximum additional approval
    365 daysTreatment-trial lookback
    3 of 4Failed tension-headache therapies
    30 daysMigraine prophylaxis recency

    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.

    Coverage Criteria

    Tension Headache

    Coverage for requests exceeding the quantity limit requires ALL of the following:

    ALL of the following

    • Chronic history of attacks, documented in the submitted progress notes.
    • Prescribed or recommended following consultation with a specialist (e.g., neurologist), as documented in the submitted progress notes.

    • At least THREE of the following FOUR therapies must have been tried and failed within the past 365 days:

      • NSAIDs (e.g., ibuprofen, naproxen).
      • Tricyclics (e.g., amitriptyline).
      • Muscle relaxants (e.g., tizanidine).
      • Non-drug therapies (e.g., relaxation training, cognitive behavior therapy, EMG biofeedback).

    Migraine Headache

    Coverage for requests exceeding the quantity limit requires ALL of the following:

    ALL of the following

    • Chronic history of attacks, documented in the submitted progress notes.
    • Current treatment failure of prophylaxis therapy within the past 30 days (e.g., metoprolol, topiramate, amitriptyline).
    • Prescribed or recommended following consultation with a specialist (e.g., neurologist), as documented in the submitted progress notes.

    • At least one medication from EACH of the following therapy classes must have been tried and failed within the past 365 days:

      • NSAIDs (e.g., ibuprofen, naproxen).

    Prior Authorization and Documentation

    Prior Authorization

    Excess-Quantity Prior Authorization Required

    Requests exceeding the existing quantity limitation require prior authorization. Approval may allow up to a maximum of an additional 120 tablets/capsules or 180 mL for liquid products above the existing limit.

    Documentation Required

    Document Required Treatment Trials

    For excess-quantity requests, document the required treatment trials and failures within the specified lookback periods.

    • Tension (muscle contraction) headaches: trial and failure of at least three of four therapies within the past 365 days: NSAIDs (e.g., ibuprofen, naproxen); tricyclics (e.g., amitriptyline); muscle relaxants (e.g., tizanidine); and non-drug therapies (relaxation training, cognitive behavior therapy, or EMG biofeedback).
    • Migraine headaches: current treatment failure of prophylaxis therapy (e.g., metoprolol, topiramate, or amitriptyline) within the past 30 days, plus trial and failure within the past 365 days of at least one medication from each required class: NSAIDs and triptans (e.g., almotriptan, rizatriptan, sumatriptan, eletriptan, naratriptan, frovatriptan, or zolmitriptan).
    Documentation Required

    Submit Progress Notes and Treatment History

    Submit progress notes and treatment history supporting the excess-quantity request, including the patient’s chronic attack history, specialist involvement, and documented treatment failures.

    • For both tension and migraine headaches, provide progress notes documenting a chronic history of attacks.
    • Include documentation that the product was prescribed or recommended after consultation with a specialist, such as a neurologist.
    • Submit records showing the applicable therapy trials and failures, including dates sufficient to verify the 30-day and 365-day lookback requirements.
    Denial Risk

    Failure to Meet Excess-Quantity Criteria

    Excess-quantity requests may be denied when the required chronic headache history, specialist involvement, or treatment-failure criteria are not documented or are not met.

    • Tension headaches: denial risk if progress notes do not show chronic attacks, specialist consultation or recommendation, and failure of at least three of the four required therapies within the past 365 days.
    • Migraine headaches: denial risk if progress notes do not show chronic attacks, specialist consultation or recommendation, current prophylaxis-treatment failure within the past 30 days, and failure of at least one medication from each required class within the past 365 days.
    • Approval is limited to a maximum additional quantity of 120 tablets/capsules or 180 mL of liquid above the existing quantity limitation.

    Policy Background

    This policy establishes the review requirements for prior authorization requests that exceed the existing quantity limitation for butalbital-containing products. Coverage review applies to products used for chronic tension-type (muscle-contraction) headaches and chronic migraine headaches, with consideration of the patient’s documented chronic attack history, specialist involvement, and failure of conventional medication or non-drug therapies. When the applicable criteria are met, approval may be granted for up to an additional 120 tablets/capsules or 180 mL of liquid above the existing quantity limitation.

    Required Treatment Trials

    Therapy categoryRequired treatment failureLookback period
    NSAIDs (for example, ibuprofen or naproxen)
    Trial and failure required as part of at least 3 of the 4 listed therapies
    Past 365 days
    Tricyclics (for example, amitriptyline)
    Trial and failure required as part of at least 3 of the 4 listed therapies
    Past 365 days
    Muscle relaxants (for example, tizanidine)
    Trial and failure required as part of at least 3 of the 4 listed therapies
    Past 365 days
    Non-drug therapies, such as relaxation training, cognitive behavior therapy, or EMG biofeedback
    Trial and failure required as part of at least 3 of the 4 listed therapies
    Past 365 days
    Medication classRequired treatment failureLookback period
    NSAIDs (for example, ibuprofen or naproxen)
    Trial and failure of at least one medication from this class
    Past 365 days
    Triptans (for example, almotriptan, rizatriptan, sumatriptan, eletriptan, naratriptan, frovatriptan, or zolmitriptan)
    Trial and failure of at least one medication from this class
    Past 365 days

    Additional Quantity Approval

    Quantity Limits
    ProductButalbital-containing products
    Tablets/capsulesUp to an additional 120 tablets/capsules above the existing quantity limitation
    Liquid formulationsUp to an additional 180 mL above the existing quantity limitation
    Policy Summary
    PayerAgency for Health Care Administration
    PolicyButalbital-Containing Products
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit prior authorization with progress notes documenting chronic attacks, specialist involvement, and the required treatment failures.
    SourceLink
    On This Page
    Coverage CriteriaPrior Authorization and DocumentationPolicy BackgroundRequired Treatment TrialsAdditional Quantity Approval
    Triptans (e.g., Axert [almotriptan], Maxalt [rizatriptan], Imitrex [sumatriptan], Relpax [eletriptan], Treximet [sumatriptan/naproxen], Amerge [naratriptan], Frova [frovatriptan], Zomig [zolmitriptan]).