WHA

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

  • Guideline ID
    GL-152688

  • Formulary
    premium

  • Effective date
    Aug 1, 2024

  • P&T approval date
    Mar 18, 2020

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

  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.
  1. The safety and effectiveness in pediatric patients has not been established [1].
  2. The American Academy of Neurology supports the use of the following medications for the prevention of episodic migraine in adult patients (with level A or B evidence): antidepressants [i.e., Elavil (amitriptyline), Effexor (venlafaxine)], antiepileptics [i.e., Depakote/Depakote ER (divalproex sodium), Topamax (topiramate)], and beta-blockers [i.e., atenolol, propranolol, nadolol, timolol, metoprolol] [4].
  • 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