CurrentNeighborhood Health Plan of Rhode IslandPolicy 3020-D

Symbravo (meloxicam/rizatriptan) and Treximet (sumatriptan/naproxen) coverage and prior authorization

This policy governs coverage and prior authorization requirements for Symbravo (meloxicam/rizatriptan) and Treximet (sumatriptan/naproxen) for the acute treatment of migraine for members whose pharmacy benefits are administered by CVS Caremark/Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySymbravo and Treximet coverage and prior authorization

Policy CodePolicy 3020-D

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization when the patient has not filled qualifying generic component(s) (>=30-day supply within past 120 days) or to document failure/intolerance to three triptans and trial of the two individual components together.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3triptans required

120lookback (days)

30dminimum fill

12duration (months)

Coverage Criteria

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Covered with criteria

Authorization may be granted when the requested drug is being prescribed for the diagnosis of migraine headache when ALL of the following criteria are met:

Covered with criteria: The patient has tried and experienced an inadequate treatment response or intolerance to THREE triptan 5-HT1 agonists.

Covered with criteria: The patient has tried the two individual components of the requested drug taken together (i.e., meloxicam plus rizatriptan or naproxen plus sumatriptan).

Symbravo and Treximet are not indicated for preventive treatment of migraine attacks. Authorization is limited to use for the acute treatment of migraine when a clear diagnosis of migraine headache has been established; if there is no response to the first treated attack, the diagnosis should be reconsidered before treating subsequent attacks with the same agent. Symbravo is not indicated for the treatment of cluster headache, and Treximet’s safety and effectiveness for cluster headache have not been established.

Because Symbravo and Treximet are intended for acute—rather than preventive—management, requests for these products for migraine prevention or for cluster headache should be denied as not indicated under this policy.

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required when patient does not meet initial step therapy or to confirm other criteria.

If claim does not meet the Initial Step Therapy criteria (see below), the claim will reject with a message indicating a prior authorization (PA) is required.
PA requests will be evaluated against the Coverage Criteria and documentation requirements.

Step Therapy

Initial Step Therapy

If the patient has filled a prescription for at least a 30-day supply of generic sumatriptan AND generic naproxen OR generic meloxicam AND generic rizatriptan within the past 120 days under a prescription benefit administered by CVS Caremark, the requested drug will be paid under that prescription benefit. If the patient does not meet the initial step therapy criteria, the claim will reject and require prior authorization.

Includes Rx and OTC products unless otherwise stated.
Timeframe: fills within the past 120 days.
Required fill quantity: at least a 30-day supply of each listed generic component.

Documentation Required

Clinical Trial History Required

Documentation that the patient has tried and had inadequate response or intolerance to three triptan 5-HT1 agonists and has tried the two individual components of the requested combination drug taken together is required for authorization.

The patient must have tried and had inadequate response or intolerance to THREE triptan 5-HT1 agonists.
The patient must have tried the two individual components of the requested drug taken together (for example, meloxicam plus rizatriptan OR naproxen plus sumatriptan).
These criteria apply when the drug is prescribed for migraine headache.

Denial Risk

Initial Step Therapy Rejection

If the patient has not filled at least a 30-day supply of the specified generic components within the past 120 days under the specified prescription benefit, the claim will reject and require prior authorization.

Rejection is automatic at claim adjudication when initial step therapy criteria are not met.
Submit a PA with supporting documentation to the PA unit for consideration.

Definitions

Symbravo

DrugSymbravo (meloxicam/rizatriptan)

IndicationAcute treatment of migraine with or without aura in adults

Not for preventionIntended for acute — not preventive — treatment of migraine

Diagnosis requirementUse only where a clear diagnosis of migraine has been established

Treximet

DrugTreximet (sumatriptan/naproxen)

IndicationAcute treatment of migraine with or without aura in adults and pediatric patients 12 years of age and older

Age limitApproved for patients >= 12 years

Diagnosis requirementUse only where a clear diagnosis of migraine has been established

Background

Symbravo (meloxicam/rizatriptan) and Treximet (sumatriptan/naproxen) are oral combination therapies indicated for the acute treatment of migraine when a clear diagnosis of migraine has been established. Treximet is approved for use in adults and in pediatric patients 12 years of age and older; Symbravo is indicated for adults.

Both products should be used to treat individual migraine attacks. If a patient does not respond to the first treated attack, the diagnosis of migraine should be reconsidered before administering the same combination product for subsequent attacks.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySymbravo and Treximet coverage and prior authorization

Policy CodePolicy 3020-D

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Symbravo (meloxicam/rizatriptan) and Treximet (sumatriptan/naproxen) coverage and prior authorization

Coverage Criteria

Coding and Lookback Rules

Provider Actions and Authorization Requirements

Definitions

Background