CurrentCentenePolicy CP.PMN.218

Lasmiditan (Reyvow) — Clinical Policy

Defines medical necessity and prior authorization criteria for lasmiditan (Reyvow) for the acute treatment of migraine in adults across Centene lines of business (Commercial, HIM, Medicaid).

Policy Summary

PayerCentene

PolicyLasmiditan (Reyvow) — Clinical Policy

Policy CodePolicy CP.PMN.218

Change TypeNo material changes

Effective DateMar 1, 2020

Next Review Date

Key ActionObtain prior authorization with documentation that approval criteria are met, including diagnosis of migraine, age ≥18, and required prior medication trials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18Minimum age

2Required triptan failures

200 mgMax daily dose

2Max tablets/day

4Max days/month

12 moTypical approval duration

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Coverage Criteria for Lasmiditan (Reyvow)

inv-01: Initial Therapy

Covered when ALL of the following are met:

Initial Migraine Coverage: 1) Diagnosis of migraine headaches; 2) Age ≥ 18 years; 3) Failure of at least TWO formulary generic 5HT1B/1D-agonist migraine medications (e.g., sumatriptan, rizatriptan, zolmitriptan) at up to maximally indicated doses unless clinically significant adverse effects are experienced or all are contraindicated; 4) For requests for quantities greater than two doses per month, BOTH: a) failure of TWO prophylactic migraine medications unless clinically significant adverse effects are experienced or all are contraindicated (see Appendix B), and b) member is being treated by or in consultation with a neurologist, headache, or pain specialist; 5) Dose does not exceed all of the following: a) 200 mg per day; b) 2 tablets per day; c) 4 days per month.see node text

Prior authorization may be required; Illinois HIM exceptions apply per IL HB 5395 for some requests

inv-02: Continuation Therapy

Continued therapy is covered when ALL of the following are met:

Continued Migraine Coverage: 1) Member meets one of the following: a) currently receiving medication via Centene benefit or previously met initial approval criteria, OR b) member is currently receiving medication and is enrolled in a state/product with continuity of care regulations; 2) Member is responding positively to therapy; 3) For dose increase requests for quantities greater than two doses per month, BOTH: a) failure of TWO prophylactic migraine medications unless clinically significant adverse effects are experienced or all are contraindicated (see Appendix B), and b) member is being treated by or in consultation with a neurologist, headache, or pain specialist; 4) If request is for a dose increase, new dose does not exceed: a) 200 mg per day; b) 2 tablets per day; c) 4 days per month.see node text

Illinois HIM exceptions apply per IL HB 5395 for some requests

Non‑FDA approved indications are not covered by this policy unless there is sufficient documentation of efficacy and safety in accordance with applicable off‑label use policies (CP.CPA.09 for commercial, HIM.PA.154 for Health Insurance Marketplace, and CP.PMN.53 for Medicaid) or evidence of coverage documents. Requests for indications outside the FDA‑approved labeling that are not addressed in this policy will be denied unless the required off‑label documentation is provided.

When state Medicaid coverage provisions conflict with this clinical policy, state Medicaid coverage provisions take precedence. Providers and reviewers should consult the applicable state Medicaid manual for any coverage provisions that apply to this policy.

Uses for indications that are not FDA‑approved and are not specifically addressed in this policy are considered not authorized without sufficient supporting documentation per the applicable off‑label use policies. Documentation must demonstrate efficacy and safety consistent with the referenced off‑label policies or evidence of coverage to be considered for approval.

Dosing and Quantity Limits

Maximum daily/period dosing

Maximum daily dose200 mg per day

Maximum tablets per day2 tablets per day

Maximum days of use per monthNo more than 4 days per month

Dosing intervalNo more than one dose per 24 hours (no more than one dose should be taken in 24 hours)

Prior Authorization, Documentation, and Step Therapy

Prior Authorization

Prior Authorization Required; Approval Duration and Quantity Limits

Prior authorization is required. Approval duration and quantity limits are governed by plan criteria and may be limited by commercial approval duration (e.g., up to 12 months or the duration of the request, whichever is less) and specific quantity limits. Requests that exceed documented commercial approval durations or the policy's quantity/ dose limits (for example, requests exceeding the maximum tablets per day or doses per month) may be denied.

Commercial approval duration: up to 12 months or duration of request, whichever is less (see plan/product specifics).
Quantity and dosing limits in policy apply (e.g., maximum tablets/day and maximum doses/month).

Documentation Required

Required Documentation

Provider must submit documentation (such as office chart notes, medication trial history, and relevant test results) supporting that the member has met all approval criteria. Documentation should include diagnosis, age, history of prior medication trials (including doses and outcomes), and prescriber specialty when applicable.

Drug and Plan Definitions

Lasmiditan (Reyvow) — product description

DrugLasmiditan (Reyvow)

MechanismSerotonin (5-HT)1F receptor agonist

FDA‑approved indicationAcute treatment of migraine with or without aura in adults

Available oral strengths50 mg, 100 mg, and 200 mg tablets

Health Plan — definition / scope note

DefinitionHealth Plan refers to a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of its affiliates.

Scope

Background

Lasmiditan (Reyvow) is a selective serotonin 5‑HT1F receptor agonist indicated for the acute treatment of migraine with or without aura in adults. It is available in oral dosing options including 50 mg, 100 mg, and 200 mg, and labeling specifies that no more than one dose should be taken in 24 hours. Lasmiditan is not indicated for the preventive treatment of migraine.

Policy Summary

PayerCentene

PolicyLasmiditan (Reyvow) — Clinical Policy

Policy CodePolicy CP.PMN.218

Change TypeNo material changes

Effective DateMar 1, 2020

Next Review Date

Key ActionObtain prior authorization with documentation that approval criteria are met, including diagnosis of migraine, age ≥18, and required prior medication trials.

SourceLink

On This Page

Examples: office notes, progress notes, medication lists, prior authorization history, consultation notes, and relevant labs.
Include evidence of trials of required agents at maximally indicated doses or documentation of intolerance/contraindication.

Documentation Required

Additional Documentation Required for Requests >2 Doses/Month

For initial requests and continuation requests seeking quantities greater than two doses per month, additional documentation is required: evidence of failure of two prophylactic migraine medications (unless contraindicated or intolerable) and documentation that the member is being treated by or in consultation with a neurologist, headache specialist, or pain specialist. Requests for dose increases above two doses per month will be denied without this documentation.

Document the two prophylactic therapy trials (agents, doses, dates, and reasons for failure).
Provide specialist prescriber or consultation notes when requesting >2 doses/month.

Step Therapy

Triptan Step Therapy and Illinois Step Therapy Bypass

Step therapy requirements apply: member must have failed at least two formulary generic 5HT1B/1D agonists at up to maximally indicated doses prior to approval, unless there is documentation of contraindication or clinically significant adverse effects. For Illinois Health Insurance Marketplace (HIM) requests, step therapy requirements do not apply per IL HB 5395 effective 1/1/2026; a step therapy bypass is available for IL HIM members.

Required failed agents example: sumatriptan, rizatriptan, zolmitriptan (formulary generics) at maximally indicated doses.
Illinois HIM: step therapy bypass effective 01/01/2026 per IL HB 5395.

Denial Risk

Non‑FDA Indications / Off‑Label Requests

Requests for non‑FDA approved (off‑label) indications that are not addressed in this policy will be denied unless sufficient documentation is provided demonstrating efficacy and safety consistent with the plan's off‑label use policies (see CP.CPA.09 for commercial, HIM.PA.154 for HIM, and CP.PMN.53 for Medicaid) and evidence of coverage documents.

Include supporting literature, rationale, and relevant clinical documentation for off‑label requests.
Reference applicable off‑label policy for required evidence standards.

Provides guidance to medical necessity determinations and coverage decisions; does not constitute a contract or guarantee of payment.

ApplicationCoverage decisions subject to plan documents, state/federal requirements, and Health Plan-level administrative policies and procedures.