Antimigraine Agents, Other

May 2026

Please refer to the Preferred Drug List for the preferred and non-preferred status of drugs.

  • All agents require prior authorization
  • For Vyepti, coverage may be provided if members meet the prior authorization (PA) criteria for “Vyepti”
  • For all other drugs, coverage may be provided if members meet PA criteria below

Initial approval criteria

Preventive treatment of migraine

    Criteria for preferred drugs

  • The requested drug is FDA-approved for the preventive treatment of migraine AND
  • The requested drug is not used in combination with botulinum toxins unless the combination therapy is FDA-approved
  • Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND
  • Requested drug is prescribed by, or in consultation with a specialist (including neurologist or pain specialist) AND
  • Patient has a diagnosis of migraine with or without aura based on International Classification of Headache Disorders (ICHD-III) diagnostic criteria AND
  • Patient has tried and failed a ≥ 1 month trial of any 2 of the following oral medications:  
  • Antidepressants (e.g., amitriptyline, venlafaxine)
  • Beta blockers (e.g., propranolol, metoprolol, timolol, atenolol)
  • Anti-epileptics (e.g., valproate, topiramate)
  • Angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (e.g., lisinopril, candesartan)
  • Initial approval is for 3 months

    Criteria for nonpreferred drugs

  • Patient must meet all initial approval criteria for preferred drug AND
  • Patient has tried and failed a 3-month trial of the preferred drug, unless contraindicated
  • Initial approval is for 3 months

Acute treatment of migraine

    Criteria for preferred drugs

  • The requested drug is FDA-approve for the acute treatment of migraine AND
  • Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND
  • Requested drug is prescribed by, or in consultation with a specialist (including neurologist or pain specialist) AND
  • Patient has a diagnosis of migraine with or without aura based on International Classification of Headache Disorders (ICHD-III) diagnostic criteria AND
  • Patient has tried and failed a ≥ 1 month trial of any 2 triptans  
  • Initial approval is for 3 months

    Criteria for nonpreferred drugs

  • Patient must meet all initial approval criteria for preferred drug AND
  • Patient has tried and failed a 3-month trial of the preferred drug, unless contraindicated
  • Initial approval is for 3 months

Treatment of episodic cluster headache

  • The requested drug is FDA-approve for the treatment of episodic cluster headache AND
  • Patient must meet the age limit indicated in the FDA-approved label of the requested drug AND
  • Requested drug is prescribed by, or in consultation with a specialist (including neurologist or pain specialist) AND
  • Patient has a diagnosis of episodic cluster headaches based on International Classification of Headache Disorders (ICHD-III) diagnostic criteria as documented in patient chart notes; AND
  • Patient has at least 5 attacks occurring in bouts (cluster periods) that meet the following criteria:
    • Severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 minutes when untreated; during part (but less than half) of the active time course of cluster headache, attacks may be less severe and/or of shorter or longer duration AND
    • Either or both of the following:
    • At least one of the following symptoms or signs ipsilateral to the headache
    • Conjunctival injection and/or lacrimation OR
    • Nasal congestion and/or rhinorrhea OR
    • Eyelid edema OR
    • Forehead and facial swelling OR
    • Miosis and/or ptosis OR
    • A sense of restlessness or agitation AND
    • Attacks have a frequency between 1 every other day to 8 every day; during part (but less than half) of the active time-course of cluster headache, attacks may be less frequent; AND
  • Patient has experienced at least two cluster periods lasting from 7 days to 365 days, separated by pain-free periods lasting at least 3 months; AND
  • Medication overuse has been ruled out by trial and failure of titrating off treatments in the past AND
  • Patient has tried and failed a ≥ 1 month trial of the following oral medications:
    • Verapamil (maximum total daily dose of 480mg to 960mg, unless contraindicated or maximum daily dose cannot be reached due to intolerance) AND
    • Topiramate (maximum total daily dose of 100mg, unless contraindicated or maximum daily dose cannot be reached due to intolerance)
  • Initial approval is for 3 months

Renewal criteria for all FDA-approved indications

  • Patient demonstrated significant decrease in the number, frequency, and/or intensity of headaches AND
  • Patient has an overall improvement in function with therapy AND
  • Has not reached the end of the cluster period, if for cluster headaches AND
  • Absence of unacceptable toxicity (e.g., intolerable injection site pain)
  • Renewal approval is for 12 months

Quantity limits

  • Quantity limits pursuant to the FDA-approved label will apply.

Questions

Provider Call Center: (844) 575-7887