CurrentNeighborhood Health Plan of Rhode IslandPolicy 3020-D

Symbravo (meloxicam/rizatriptan) and Treximet (sumatriptan/naproxen) step therapy and prior authorization policy

Defines initial step therapy and prior authorization criteria for Symbravo and Treximet for acute treatment of migraine (adults; Treximet also ages 12+), including required prior use of individual components or generics and failure of prior triptans. Applies to prescription benefit administered by CVS Caremark.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySymbravo (meloxicam/rizatriptan) and Treximet (sumatriptan/naproxen) step therapy and prior authorization policy

Policy CodePolicy 3020-D

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf patient has filled a 30-day supply of the specified generic component pair within the past 120 days under CVS Caremark, route payment to the prescription benefit; otherwise submit prior authorization with documentation of migraine diagnosis, trial/failure of three triptans, and trial of the two individual components taken together.

SourceLink

POLICY UPDATE CHANGES

No material changes

2Drugs referenced

3Required failed triptans

120Lookback window (days)

12Duration of approval (months)

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Coverage Summary

Covered with criteria: Symbravo (meloxicam/rizatriptan) and Treximet (sumatriptan/naproxen) are covered with prior authorization criteria. The policy implements an Initial Step Therapy routing rule: if the patient has filled at least a 30-day supply within the past 120 days of the specified generic component pair(s) under the CVS Caremark prescription benefit, the requested combination product will be paid under that benefit; otherwise the claim will reject and prior authorization criteria apply. For full authorization, the patient must meet the prior authorization criteria including failure/intolerance to three triptan agents and trial of the two individual components taken together. Symbravo is indicated for adults only; Treximet is indicated for adults and pediatric patients 12 years and older. Neither product is indicated for migraine prevention or cluster headache.

Quick facts and policy thresholds

Step therapy lookback windowPatient has filled at least a 30-day supply within the past 120 days

Required failed triptans3 triptan agents (inadequate response or intolerance)

Duration of approval12 months

Drugs referenced2 (Symbravo and Treximet)

Initial Step Therapy (routing to prescription benefit)

If the patient has prior fills for generic components within past 120 days, the requested combination product will be paid under prescription benefit; otherwise PA required.

ALL of the following

ONE OF
- generic sumatriptan AND generic naproxen
- generic meloxicam AND generic rizatriptan

Billing Rule

Prior Authorization / Coverage Criteria (migraine)

Prior Authorization / Coverage Criteria for migraine diagnosis

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

ALL of the following

Patient has tried and experienced an inadequate treatment response or intolerance to THREE triptan 5-HT1 agoniststriptan_trial_count = 3
Patient has tried the two individual components of the requested drug taken together (i.e., meloxicam plus rizatriptan OR naproxen plus sumatriptan)

Prior Authorization

Prior authorization clinical requirements

Unproven / Exclusions

Neither product is indicated for migraine prevention or for cluster headache. Symbravo is specifically not indicated for preventive treatment and is indicated only in adults; Treximet is not indicated for prevention and its safety/effectiveness for cluster headache have not been established. Treat age limitations as exclusions/limits: Symbravo is not indicated for pediatric patients, whereas Treximet is indicated down to age 12.

Applicable Codes

Policy identifiermixed

3020-D

Reference / policy number

Clinical Evidence & References

Evidence and references: Package inserts are cited as the primary references for these products: Symbravo [package insert], Axsome Therapeutics; January 2025 and Treximet [package insert], Currax Pharmaceuticals LLC; February 2024. Both products are indicated for the acute treatment of migraine with or without aura; Symbravo for adults only and Treximet for adults and pediatric patients 12 years and older.

Background & Definitions

Background and scope: Symbravo and Treximet are indicated for the acute treatment of migraine with or without aura. Symbravo is indicated for adults only; Treximet is indicated for adults and pediatric patients aged 12 and older. Both products should be used only when a clear diagnosis of migraine has been established, and neither is indicated for preventive treatment of migraine attacks. The policy defines initial step therapy and prior authorization criteria for these combination products and applies to the prescription benefit administered by CVS Caremark.

Definitions: Initial Step Therapy — Requirement that patients must have recent fills of the individual generic components (specified as either generic sumatriptan AND generic naproxen OR generic meloxicam AND generic rizatriptan) to route coverage under the prescription benefit rather than triggering prior authorization. Specifically, the patient must have filled at least a 30-day supply within the past 120 days under a prescription benefit administered by CVS Caremark for the specified generic component pair.

Revision History

2024-04-01ReviewLatest

Policy last reviewed

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySymbravo (meloxicam/rizatriptan) and Treximet (sumatriptan/naproxen) step therapy and prior authorization policy

Policy CodePolicy 3020-D

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

Step therapy routing to prescription benefit

If the patient has filled at least a 30‑day supply of the specified generic component pair within the past 120 days under the prescription benefit administered by CVS Caremark, the requested combination product will be paid under that prescription benefit. If not, the claim will reject indicating a prior authorization is required.

Allowed generic component pairs: generic sumatriptan + generic naproxen; generic meloxicam + generic rizatriptan
Lookback window: filled at least a 30‑day supply within the past 120 days
Beneficiary/payer: prescription benefit administered by CVS Caremark

Submit prior authorization documentation that the patient has a diagnosis of migraine and evidence of inadequate response or intolerance to three triptan agents, and documentation that the patient has tried the two individual components of the requested combination taken together.

Required triptan trials: inadequate response or intolerance to THREE triptan 5-HT1 agonists
Required component trials (taken together): meloxicam + rizatriptan OR naproxen + sumatriptan

Documentation Required

Re-evaluate diagnosis after nonresponse

If the patient has no response to the first migraine attack treated with Symbravo or Treximet, the migraine diagnosis should be reconsidered and this reassessment documented before treating subsequent attacks with the same product.

Operational note for clinicians: document reassessment of diagnosis and rationale before additional prescriptions after a nonresponse to the first treated attack