Pharmacy Prior Authorization Criteria

Elyxyb (celecoxib) Oral Solution - PA, NF

Indications for Prior Authorization

Elyxyb (celecoxib) Oral Solution

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

  Limitations of use: ELYXYB is not indicated for the preventive treatment of migraine.

Criteria

Elyxyb

Prior Authorization

Length of Approval: 12 Month(s)

• Diagnosis of migraine with or without aura
AND
• Trial and failure, contraindication or intolerance to two of the following generics:
• Almotriptan tablet
• Eletriptan tablet
• Frovatriptan tablet
• Naratriptan tablet
• Rizatriptan tablet/rizatriptan orally dissolving tablet (ODT)
• Sumatriptan tablet/nasal spray
• Zolmitriptan tablet/zolmitriptan ODT

Elyxyb

Non Formulary

Length of Approval: 12 Month(s)

• Diagnosis of migraine with or without aura
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure, contraindication or intolerance to two of the following generics:
• Almotriptan tablet
• Eletriptan tablet
• Frovatriptan tablet
• Naratriptan tablet
• Rizatriptan tablet/rizatriptan orally dissolving tablet (ODT)
• Sumatriptan tablet/nasal spray
• Zolmitriptan tablet/zolmitriptan ODT

P & T Revisions

2024-04-24, 2023-05-03, 2022-05-09

References

1. Elyxyb Prescribing Information. Dr. Reddy’s Laboratories Limited. Telangana, India. October 2021.

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Revision History

• 2024-04-24: 2024 annual review. Background changes.
• 2023-05-03: Annual review - no changes.
• 2022-05-09: New PA program for Elyxyb.

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