CurrentNeighborhood Health Plan of Rhode IslandPolicy 3020-D 07-2022

Treximet St Post Pa Policy 3020 D 07 2022

This CVS Caremark step therapy/post-prior authorization policy governs coverage of Treximet (sumatriptan/naproxen) for acute treatment of migraine in patients ≥12 years, specifying initial step requirements (trial of generic sumatriptan + naproxen) and prior authorization clinical criteria (diagnosis of migraine, failure/intolerance to three triptans, trial of sumatriptan with naproxen). Applies to prescription benefits administered by CVS Caremark.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTreximet St Post Pa Policy 3020 D 07 2022

Policy CodePolicy 3020-D 07-2022

Change TypeClarifiedRevised

Effective Date

Next Review Date

Key ActionIf patient has not filled a ≥30-day supply of generic sumatriptan AND generic naproxen within the past 120 days under CVS Caremark, the claim will reject and a prior authorization is required; requests will be evaluated against the PA criteria.

SourceLink

POLICY UPDATE CHANGES

Policy identifies initial step therapy requirement of at least a 30-day supply of generic sumatriptan AND generic naproxen within the past 120 days.

Prior authorization coverage criteria specify diagnosis of migraine, failure/intolerance to three triptans, and trial of sumatriptan with naproxen.

3Required triptan trials

120Look-back period (days)

30Minimum fill duration (days)

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What this change bulletin covers

Treximet (sumatriptan/naproxen) is FDA-approved for the acute treatment of migraine with or without aura in patients 12 years and older. It is not indicated for migraine prevention and its effectiveness in cluster headache has not been established. Under this CVS Caremark policy, Treximet coverage for prescription benefits administered by CVS Caremark is governed by an initial step therapy requirement and post-step prior authorization rules. Specifically, if the patient has filled a prescription for at least a 30-day supply of generic sumatriptan AND a 30-day supply of generic naproxen within the past 120 days, the requested drug will be paid under the prescription benefit; if the initial step is not met the claim will reject and a prior authorization is required, and PA requests are evaluated against the coverage criteria (diagnosis of migraine, failure/intolerance to three triptans, and trial of sumatriptan with naproxen).

Key thresholds and stats

Initial step fill requirement>= 30-day supply of generic sumatriptan AND >= 30-day supply of generic naproxen within past 120 days

Triptan failure requirementFailure/intolerance to 3 different 5-HT1 agonists (triptans)

Age>= 12 years

Required triptan trials3

Look-back period120 days

Minimum fill duration30 days

Coverage criteria and step therapy logic

Initial Step Therapy

If the patient has filled the required generics within the look-back period, the requested drug will be paid under the prescription benefit; otherwise the claim will reject and PA is required.

Sumatriptan fill: Patient has filled a prescription for at least a 30-day supply of generic sumatriptan within the past 120 days under a prescription benefit administered by CVS Caremark>=30-day supply; look-back 120 days
Naproxen fill: Patient has filled a prescription for at least a 30-day supply of generic naproxen within the past 120 days under a prescription benefit administered by CVS Caremark>=30-day supply; look-back 120 days

Prior Authorization (Coverage Criteria)

Relevant drug codes and identifiers

Relevant drugmixed

Treximet	Brand name combination product (sumatriptan/naproxen) for acute migraine treatment
sumatriptan (generic)	Generic 5-HT1 agonist (triptan) referenced for step therapy
naproxen (generic)	Generic NSAID referenced for step therapy

What providers must do

Prior Authorization

Prior authorization required if initial step not met

If the patient has not filled at least a 30-day supply of generic sumatriptan AND at least a 30-day supply of generic naproxen within the past 120 days under a prescription benefit administered by CVS Caremark, the claim will reject and a prior authorization is required. Requests will then be evaluated against the prior authorization criteria by the PA unit.

Minimum fill: ≥ 30-day supply of generic sumatriptan
Minimum fill: ≥ 30-day supply of generic naproxen
Look-back period: past 120 days
If criteria not met: claim rejects with message that PA is required; requests sent to PA unit for evaluation

Documentation Required

Support diagnosis and prior trials

For prior authorization approval, document a diagnosis of migraine headache and the patient’s prior treatment history showing inadequate response or intolerance to three different 5-HT1 agonists (triptans), and a trial of sumatriptan taken with naproxen. Include clinical details and dates to support each item in the PA submission.

Definitions and references

Initial Step Therapy: Requirement to have filled a prescription for at least a 30-day supply of generic sumatriptan AND a 30-day supply of generic naproxen within the past 120 days under a prescription benefit administered by CVS Caremark; meeting this requirement allows payment under the prescription benefit, otherwise the claim will reject and a prior authorization is required.

Prior Authorization (PA): Authorization required when initial step therapy criteria are not met; PA coverage is granted when the patient has a diagnosis of migraine headache, has tried and experienced inadequate response or intolerance to three different 5-HT1 agonists (triptans), and has tried sumatriptan taken with naproxen. Treximet is for acute migraine treatment and not for prevention or cluster headache (limitations of use).

Evidence: Referenced materials include the Treximet package insert (April 2021) and guideline/clinical references such as American Headache Society and American Academy of Neurology guidance and clinical databases (Lexicomp, Micromedex) supporting the indication and clinical context for use.

Reference: Treximet [package insert]. Morristown, NJ: Pernix Therapeutics, LLC; April 2021; and guideline/clinical references cited by CVS Caremark (e.g., American Headache Society, AAN practice guideline, Lexicomp, Micromedex).

Policy changes in this bulletin

policy_clarified

Initial step therapy requirement clarified: patient must have filled a ≥30-day supply of generic sumatriptan AND a ≥30-day supply of generic naproxen within the past 120 days to have the requested drug paid; if initial step not met, the claim will reject and prior authorization is required.

policy_revisedLatest

Prior authorization criteria revised/applied to Treximet PA evaluations: coverage requires diagnosis of migraine, failure/intolerance to THREE 5‑HT1 agonists (triptans), and a trial of sumatriptan taken with naproxen.