SYMBRAVO (meloxicam and rizatriptan) prior authorization
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Prior authorization requirements for SYMBRAVO (combination rizatriptan/meloxicam) for acute treatment of migraine in adults under Mississippi Division of Medicaid; describes initial and re-authorization criteria, dosing limits, and documentation expectations.
No material clinical or coverage changes in this revision.
Coverage Criteria for SYMBRAVO
Initial Authorization
Covered when ALL of the following are met:
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Re-Authorization
Covered when BOTH of the following are met:
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This policy applies only to the acute treatment of migraine and is not indicated for migraine prevention. Requests for SYMBRAVO for preventative therapy should be denied or redirected per standard coverage processes; coverage and prior authorization criteria in this document assume use for acute migraine episodes only.
Dosing Limits and Quantity Limits
Prior Authorization, Step Therapy, and Documentation Requirements
Prior authorization required — initial approval 12 months; age ≥18
Prior authorization is required for SYMBRAVO. When all initial criteria are met, initial approval will be considered for 12 months; the policy requires the patient to be 18 years of age or older.
Step therapy — trials of triptans and CGRP inhibitors required
Prior to approval, the patient must have an inadequate response (or documented contraindication where specified) to required prior therapies: at least two preferred triptans and at least two preferred CGRP inhibitors.
- Document inadequate response to at least two preferred triptans.
- Document inadequate response or contraindication to at least two preferred CGRP inhibitors.
Required documentation — Universal PA Form and clinical support
Submit the Universal PA Form and supporting clinical documentation with the prior authorization request.
- Include documented diagnosis of migraine.
- Include documentation of prior treatment trials (two preferred triptans and two preferred CGRP inhibitors) or documented contraindications.
- Provide rationale explaining why the patient cannot take a triptan and an NSAID separately.
- If requesting more than 9 tablets per 31 days, provide supporting rationale.
Denial triggers — common documentation and dosing omissions
Claims or PA requests may be denied if required information is missing or criteria are not met.
- Missing documentation that the patient is ≥18 years of age.
- Missing documented diagnosis of migraine.
- No documentation of inadequate response to two preferred triptans.
- No documentation of inadequate response or contraindication to two preferred CGRP inhibitors.
- No rationale explaining why the combination product is necessary (cannot take triptan and NSAID separately).
- Prescribed dose exceeding 1 tablet per day or 9 tablets per 31 days without rationale.
Indication and Formulation Details
Background
SYMBRAVO is a fixed-dose oral tablet combining the triptan rizatriptan (10 mg) with the NSAID meloxicam (20 mg). The product is indicated for the acute treatment of migraine in adults and is supplied as a single tablet containing both active ingredients; dosing guidance recommends one tablet orally as needed, not to exceed one tablet per day.
Revision History
Policy effective date published for SYMBRAVO (meloxicam and rizatriptan) prior authorization criteria.
Initial authorization criteria established: 12-month initial approval with requirements including age ≥18, documented migraine diagnosis, acute-use only, trials of two preferred triptans and two preferred CGRP inhibitors (or contraindications), rationale for combined product, and dose limits (≤1 tablet/day; ≤9 tablets/31 days).
Re-authorization criteria established: 12-month re-approval contingent on positive clinical response and adherence to dose limits (≤1 tablet/day; ≤9 tablets/31 days).
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