CurrentCignaPolicy N/A

Migraine - Elyxyb Prior Authorization Policy

Defines Cigna's prior authorization requirements for Elyxyb for the acute treatment of migraine in adults, including covered indication, required trials or contraindications to triptans, and noncovered uses.

Policy Summary

PayerCigna

PolicyMigraine - Elyxyb Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateApr 2, 2025

Key ActionObtain prior authorization and document patient age, prior triptan trial or contraindication to triptans to approve Elyxyb for acute migraine for up to 1 year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18Minimum age for coverage

1 yearApproval duration

1 trialPrior triptan requirement

Not coveredNoncovered uses

Coverage Criteria for Elyxyb (celecoxib oral solution)

Initial approval criteria

Approve Elyxyb for acute migraine when ALL of the following are met:

ALL of the following

Age: Patient is ≥ 18 years of age>= 18 years
Prior therapy or contraindication: Patient has tried at least one triptan therapy OR, according to the prescriber, has a contraindication to triptan(s)n>=1
Examples of contraindications to triptans include a history of coronary artery disease; cardiac accessory conduction pathway disorders; history of stroke, transient ischemic attack, or hemiplegic or basilar migraine; peripheral vascular disease; ischemic bowel disease; uncontrolled hypertension; or severe hepatic impairment.

Policy Summary

PayerCigna

PolicyMigraine - Elyxyb Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateApr 2, 2025

Key ActionObtain prior authorization and document patient age, prior triptan trial or contraindication to triptans to approve Elyxyb for acute migraine for up to 1 year.

SourceLink

On This Page

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Provider Actions, Authorization and Step Therapy

Prior Authorization

Prior Authorization Required

Prior authorization required. Approvals are provided for 1 year when criteria are met.

Note

Approval Criteria Summary

Approval criteria summary: For the FDA‑approved indication of acute migraine treatment, patient must be ≥ 18 years of age and must have tried at least one triptan or have a documented contraindication to triptans.

Step Therapy

Step Therapy — Triptan First

Step therapy requirement: Trial of at least one triptan is required prior to approval unless the prescribing clinician documents a contraindication to triptan therapy.

Examples of triptan agents: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan.

Documentation Required

Required Documentation and Plan Terms

Required documentation and plan terms: Follow the member's benefit plan for coverage determinations. Submit clinical information demonstrating the patient meets approval criteria (age ≥ 18 and either prior triptan trial details or documentation of contraindication). Examples of acceptable documentation include medication history showing trial and failure or intolerance of a triptan, or clinical notes documenting a contraindication (e.g., coronary artery disease, stroke/TIA, uncontrolled hypertension, peripheral vascular disease, ischemic bowel disease, severe hepatic impairment, or other prespecified contraindications).

Follow applicable benefit plan documents; plan terms supersede policy when in conflict.
Document duration of approval: 1 year when criteria met.

Denial Risk

Noncovered Indications

Noncovered indications — uses other than acute treatment of migraine are considered experimental/investigational and will be denied.

Elyxyb is not covered for management of acute pain unrelated to migraine headache.

Background

Background: Elyxyb is a celecoxib oral solution, an NSAID indicated for the acute treatment of migraine with or without aura in adults. Migraine can present as episodic or chronic disease; chronic migraine is defined as headache on ≥ 15 days per month for > 3 months with migraine features on ≥ 8 days per month.

Clinical practice guidelines identify triptans (for example, sumatriptan, rizatriptan, zolmitriptan and others) as the gold-standard acute therapy for migraine attacks. NSAIDs, including celecoxib formulations, are an option for patients with mild to moderate attacks or when triptans are contraindicated or not tolerated.

Per the policy, prior authorization is required for Elyxyb and approvals are limited to the FDA‑approved acute migraine indication with specified criteria (including age and prior triptan trial or documented contraindication). Approvals are provided for a finite duration when criteria are met.

Definitions

Chronic migraine definition

DefinitionHeadache occurring on ≥ 15 days per month for more than 3 months, with migraine features on ≥ 8 days per month.

Timeframe requiredMore than 3 months of headache occurrence.

Frequency threshold≥ 15 days per month overall; migraine features on ≥ 8 of those days per month.

DistinctionEpisodic migraine is < 15 days per month; chronic migraine is ≥ 15 days per month.

Elyxyb definition

Generic name / formulationCelecoxib oral solution (Elyxyb).

IndicationAcute treatment of migraine with or without aura in adults.

Limitation of useNot indicated for preventive treatment of migraine.

Drug classNonsteroidal anti-inflammatory drug (NSAID).