CurrentNeighborhood Health Plan of Rhode IslandPolicy 3020-D

Coverage Criteria for Symbravo (meloxicam/rizatriptan) and Treximet (sumatriptan/naproxen)

This policy governs coverage and prior authorization criteria for Symbravo (meloxicam/rizatriptin) and Treximet (sumatriptan/naproxen) for acute treatment of migraine in members covered under the plan.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoverage Criteria for Symbravo and Treximet

Policy CodePolicy 3020-D

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization when step therapy criteria are not met and document trials of three triptans plus trials of the two individual components taken together.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsDuration of approval

3Required prior triptan trials

120 daysStep therapy look-back

Coverage and Authorization Criteria

Coverage criteria for approval

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:

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Primary criteria: Patient has tried and experienced an inadequate treatment response or intolerance to THREE triptan 5-HT1 agonists3 triptans failed/intolerant

Trials must be documented in the medical record (treatment duration, reason for discontinuation).

Component trials: Patient has tried the two individual components of the requested drug taken together (i.e., meloxicam plus rizatriptan OR naproxen plus sumatriptan)both components tried together

Documented concurrent or combination use of the two components is required.

These combination products are not indicated for the prevention of migraine attacks and are not indicated for the treatment of cluster headache. Both product labels state they should be used only when a clear diagnosis of migraine has been established and recommend reconsidering the diagnosis if there is no response to the first treated attack.

Coding and Step-Therapy Lookback

Referenced productsmixed

Symbravo	meloxicam/rizatriptan (brand and generic names and all dosage forms)
Treximet	sumatriptan/naproxen (brand and generic names and all dosage forms)

Step therapy look-back

Look-back period>= 120 days

Required prior fill duration>= 30-day supply

Products counted for step therapyGeneric sumatriptan + generic naproxen OR generic meloxicam + generic rizatriptan

Provider Requirements and Prior Authorization

Prior Authorization

PA required if initial step therapy not met

Prior authorization is required when initial step therapy criteria are not met. If the patient has not met the Initial Step Therapy requirement (see separate step-therapy callout), the claim will reject and a prior authorization (PA) must be submitted for review. The PA evaluation will follow the full authorization/coverage criteria.

Claims will reject if Initial Step Therapy criteria are not met (see below).
If claim rejects, submit PA for review; PA criteria require documentation of prior trials as outlined in the coverage criteria.

Step Therapy

Initial Step Therapy requirement

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 this Initial Step Therapy requirement, the claim will reject with a message indicating that a prior authorization is required.

Required prior fill: ≥30-day supply of generic sumatriptan + generic naproxen OR generic meloxicam + generic rizatriptan within the past 120 days.
Include Rx and OTC products unless otherwise stated.

Documentation Required

Documentation note

Documentation submitted with a PA request should demonstrate either: (a) a prior ≥30-day supply fill of generic sumatriptan plus generic naproxen within the past 120 days, or (b) a prior ≥30-day supply fill of generic meloxicam plus generic rizatriptan within the past 120 days. If neither prior fill can be documented, include clinical justification for why the step-therapy agents were not appropriate or tolerated.

Document date(s) and pharmacy benefit where prior fills occurred (CVS Caremark-administered benefits).
If prior fills are unavailable, provide documentation of intolerance or inadequate response to the required agents.

Product Definitions

Symbravo

ProductSymbravo

Active componentsmeloxicam and rizatriptan

IndicationAcute treatment of migraine with or without aura in adults

Treximet

ProductTreximet

Active componentssumatriptan and naproxen

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

Clinical Background

Symbravo (meloxicam/rizatriptan) and Treximet (sumatriptan/naproxen) are indicated for the acute treatment of migraine with or without aura. Treximet’s label additionally notes approval for patients aged 12 years and older, and both labels emphasize use only when a clear diagnosis of migraine has been established.