Pharmacy Prior Authorization Criteria

Reyvow (lasmiditan) - PA, NF

Indications for Prior Authorization

Reyvow (lasmiditan)

• For diagnosis of Migraine
  Indicated for the acute treatment of migraine with or without aura in adults.

  Limitations of Use: Reyvow is not indicated for the preventive treatment of migraine.

Criteria

Reyvow

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)

• Diagnosis of migraine with or without aura
AND
• Will be used for the acute treatment of migraine
AND
• Patient has less than 15 headache days per month [2]
AND
• Patient is 18 years of age or older [A]
AND
• One of the following: [3]
• Trial and failure or intolerance to two triptans (e.g., eletriptan, rizatriptan, sumatriptan)
• Contraindication to all triptans
AND
• If patient has 4 or more headache days per month, patient must be currently treated with one of the following: [B, 3]:
• Elavil (amitriptyline) or Effexor (venlafaxine) unless there is a contraindication or intolerance to these medications
• Depakote/Depakote ER (divalproex sodium) or Topamax (topiramate) unless there is a contraindication or intolerance to these medications
• A beta blocker (i.e., atenolol, propranolol, nadolol, timolol, or metoprolol) unless there is a contraindication or intolerance to these medications
• Atacand (candesartan) unless there is a contraindication or intolerance to this medication
• Generic lisinopril unless there is a contraindication or intolerance to this medication
AND
• Will not be used concomitantly with central nervous system (CNS) depressants (e.g., alprazolam, phenobarbital, alcohol)
AND
• Prescriber attests that the patient has been counseled and has agreed to adhere to the following: Will follow instructions to not drive or operate machinery until at least 8 hours after taking each dose of Reyvow
AND
• Trial and failure, contraindication, or intolerance to two of the following:
• Nurtec
• Ubrelvy
• Zavzpret

Reyvow

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient has experienced a positive response to therapy (e.g., reduction in pain, photophobia, phonophobia, nausea)
AND
• Will not be used for preventive treatment of migraine
AND
• Trial and failure, contraindication, or intolerance to two of the following:
• Nurtec
• Ubrelvy
• Zavzpret

Reyvow

Non Formulary

Length of Approval: 3 Month(s)

• Submission of medical records (e.g., chart notes) confirming a diagnosis of migraine with or without aura
AND
• Submission of medical records (e.g., chart notes) confirming drug will be used for the acute treatment of migraine
AND
• Submission of medical records (e.g., chart notes) confirming patient has less than 15 headache days per month [2]
AND
• Patient is 18 years of age or older [A]
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming one of the following: [3]
• Trial and failure or intolerance to two triptans (e.g., eletriptan, rizatriptan, sumatriptan)
• Contraindication to all triptans
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming that if patient has 4 or more headache days per month, patient must be currently treated with one of the following: [B, 3]:
• Elavil (amitriptyline) or Effexor (venlafaxine) unless there is a contraindication or intolerance to these medications
• Depakote/Depakote ER (divalproex sodium) or Topamax (topiramate) unless there is a contraindication or intolerance to these medications
• A beta blocker (i.e., atenolol, propranolol, nadolol, timolol, or metoprolol) unless there is a contraindication or intolerance to these medications
• Atacand (candesartan) unless there is a contraindication or intolerance to this medication
• Generic lisinopril unless there is a contraindication or intolerance to this medication
AND
• Will not be used concomitantly with central nervous system (CNS) depressants (e.g., alprazolam, phenobarbital, alcohol)
AND
• Submission of medical records (e.g., chart notes) confirming that the patient has been counseled and has agreed to adhere to the following: Will follow instructions to not drive or operate machinery until at least 8 hours after taking each dose of Reyvow
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure, contraindication, or intolerance to two of the following:
• Nurtec
• Ubrelvy
• Zavzpret

P & T Revisions

2024-08-27, 2024-06-05, 2024-03-06, 2023-06-26, 2023-05-03, 2023-03-02, 2022-03-03, 2021-03-04, 2020-12-15, 2020-07-29, 2020-03-04

References

1. Reyvow Prescribing Information. Lilly USA, LLC. Indianapolis , IN. September 2022.
2. Goadsby PJ, Wietecha LA, Dennehy EB, et al. Phase 3 randomized, placebo-controlled, double-blind study of lasmiditan for acute treatment of migraine. Brain. 2019 Jul 1;142(7):1894-1904.
3. AHS Consensus Statement. Update on integrating new migraine treatments into clinical practice. Headache. 2021 Jul;61(7):1021-1039.
4. Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2016 May 10;86(19):1818-26.

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Revision History

• 2024-08-27: Corrected spelling error. No change to clinical content.
• 2024-06-05: Removed prescriber requirement and updated background.
• 2024-03-06: Annual review: Updated criteria and background.
• 2023-06-26: Added drug-specific NF criteria.
• 2023-05-03: Per Appeals team feedback, removed criterion "will not be used for preventative tx of migraine" from initial criteria. Also reformatted T/F criteria for clarity (no changes to clinical intent).
• 2023-03-02: Annual review: Background updates.
• 2022-03-03: Annual review: Updated criteria and background.
• 2021-03-04: Annual review: Background updates.
• 2020-12-15: Updated prescriber requirement.
• 2020-07-29: Added embedded step.
• 2020-03-04: New program

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