CurrentMass General Brigham Health PlanPolicy N/A

Dihydroergotamine mesylate nasal spray prior authorization (pharmacy benefit)

Prior authorization policy governing coverage of dihydroergotamine mesylate nasal spray for treatment of acute migraine in Mass General Brigham Health Plan commercial/exchange members under the pharmacy benefit.

Policy Summary

PayerMass General Brigham Health Plan

PolicyDihydroergotamine mesylate nasal spray prior authorization (pharmacy benefit)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization demonstrating diagnosis of acute migraine, age ≥18, prior inadequate response or contraindication to intranasal sumatriptan and zolmitriptan, and quantity ≤8 units per 30 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercial/ExchangeApplicable plan

18+Minimum age

8/30dQuantity limit

6 moInitial approval

1 yrReauth duration

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Coverage Criteria

Initial Approval

Approval will be granted if ALL of the following criteria are met and documentation provided:

Initial approval: Member has a diagnosis of acute migraine headaches with or without aura

Documentation required

Initial approval: Member is 18 years of age or older>= 18 years

Documentation required

Initial approval: Member has had inadequate response, adverse reaction, or contraindication to intranasal sumatriptan

Documentation required

Initial approval: Member has had inadequate response, adverse reaction, or contraindication to intranasal zolmitriptan (Zomig)

Documentation required

Initial approval: Quantity prescribed does not exceed 8 units (vials) per 30 days<= 8 units per 30 days

Limit applies to initial and ongoing therapy

Continuation Therapy / Reauthorization

Reauthorization will be granted when the following condition is documented:

Reauthorization: Documentation indicating a positive response to therapy

Initial approvals are for 6 months; reauthorizations granted for 1 year

New-to-Plan Members

New-to-plan current therapy: Authorization may be granted for members who are new to the plan and currently receiving treatment with dihydroergotamine nasal spray (excluding when the product is obtained as samples or via manufacturer's patient assistance program)

Documentation of current treatment required

Product obtained only as samples or via the manufacturer's patient assistance program is excluded from consideration for authorization. Requests for coverage must be for dispensed product rather than samples or assistance-supplied medication, and such sample or patient-assistance supplies should not be used to justify an authorization request.

Provider Actions / Authorization Requirements

Prior Authorization

Prior authorization required for Commercial/Exchange pharmacy benefit

Prior authorization is required for Commercial/Exchange pharmacy benefit members. Approval will be granted when all coverage criteria are met: diagnosis of acute migraine, age ≥18, prior inadequate response/adverse reaction/contraindication to intranasal sumatriptan and intranasal zolmitriptan, and quantity ≤8 units per 30 days.

Applicable plan: Commercial/Exchange
Benefit: Pharmacy benefit
Approval conditioned on meeting all criteria listed in policy

Step Therapy

No step therapy program specified

This policy does not implement a step therapy program for dihydroergotamine nasal spray.

Definitions

Indication — Acute migraine headaches

IndicationAcute migraine headaches with or without aura.

Mechanism (brief)Acts on serotonin (5HT), noradrenaline, and dopamine receptors on intracranial blood vessels causing vasoconstriction.

Therapeutic useFor acute treatment of migraine attacks; not indicated for migraine prevention.

Background

Dihydroergotamine mesylate nasal spray is indicated for the acute treatment of migraine with or without aura and acts on serotonin, noradrenaline, and dopamine receptors resulting in intracranial vasoconstriction. Authorization may be granted for members who are new to the plan only when they are currently receiving treatment with dihydroergotamine nasal spray; this allowance does not apply when the product was obtained solely as samples or through the manufacturer's patient assistance program.

Policy Summary

PayerMass General Brigham Health Plan

PolicyDihydroergotamine mesylate nasal spray prior authorization (pharmacy benefit)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2022

Next Review DateN/A

SourceLink

On This Page

Documentation Required

Required documentation to support authorization

Include documentation showing: diagnosis of acute migraine (with or without aura), patient age (18 years or older), prior inadequate response, adverse reaction, or contraindication to intranasal sumatriptan and intranasal zolmitriptan. For reauthorization, submit documentation indicating a positive response to therapy.

Document diagnosis of acute migraine with or without aura
Document patient is ≥18 years old
Document inadequate response/AE/contraindication to intranasal sumatriptan
Document inadequate response/AE/contraindication to intranasal zolmitriptan
For continuation: evidence of positive response to therapy

Denial Risk

Denial risk: new-to-plan and criteria failures

Requests for members new to the plan who are not currently receiving dihydroergotamine nasal spray (excluding products obtained as samples or via manufacturer's patient assistance program) are not supported; failure to meet the stated criteria (diagnosis, age, prior triptan trials, quantity limit) may result in denial.

New-to-plan allowance applies only if member is currently receiving treatment with the product
Products obtained solely as samples or through manufacturer's patient assistance program are excluded from consideration