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Table 14: Headache Therapy


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Drug Category: Pain and Inflammation

Medication Class/Individual Agents: Butalbitals, CGRP Inhibitors, Ergot Alkaloids, and Serotonin Receptor Agents

I. Prior-Authorization Requirements

 Headache Therapy – Butalbital-Containing Agents

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

butalbital / aspirin / caffeine / codeine PA  
butalbital / aspirin / caffeine capsule PA  
butalbital / aspirin / caffeine tablet PA   - < 18 years and PA > 20 units/month
butalbital 25 mg / acetaminophen 325 mg tablet PA  
butalbital 50 mg / acetaminophen 300 mg PA  
butalbital 50 mg / acetaminophen 300 mg / caffeine 40 mg PA  
butalbital 50 mg / acetaminophen 300 mg / caffeine 40 mg / codeine 30 mg PA  
butalbital 50 mg / acetaminophen 325 mg PA  
butalbital 50 mg / acetaminophen 325 mg / caffeine 40 mg / codeine 30 mg PA   - < 18 years and PA > 20 units/month
butalbital 50 mg / acetaminophen 325 mg / caffeine 40 mg capsule PA  
butalbital 50 mg / acetaminophen 325 mg / caffeine 40 mg solution PA  
butalbital 50 mg / acetaminophen 325 mg / caffeine 40 mg tablet PA   - < 18 years and PA > 20 units/month

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

 

Contraindications to Triptans:

  • history, presence, symptoms, or signs of ischemic heart disease (e.g., angina, MI, stroke, TIA), coronary artery vasospasm, or other significant underlying cardiovascular disease
  • uncontrolled hypertension
  • concurrent use or use within 24 hours of ergotamine-containing products or ergot-type medications (e.g., dihydroergotamine, methysergide)
  • concurrent use with MAO inhibitor therapy or within two weeks of MAO inhibitor discontinuation
  • use within 24 hours of treatment with another triptan
  • management of hemiplegic or basilar migraine
  • hypersensitivity to the product or any of its ingredients

Do not exceed the maximum recommended dose per 24-hour period.

Orally Disintegrating Tablets:

  • Place tablet on tongue, where it will be dissolved and swallowed with saliva.
  • Inform phenylketonurics that tablets contain phenylalanine.

Migraine prophylaxis (e.g., amitriptyline, propranolol, timolol) may be considered for the following conditions:

  • migraine occurs ≥ twice monthly and produces disability lasting ≥ three days per month
  • contraindication to, or failure of, acute treatments
  • abortive medications are used > twice per week
  • other severe migraine conditions
 

 Headache Therapy – Calcitonin Gene-Related Peptide (CGRP) Inhibitors

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

atogepant Qulipta PD PA  
eptinezumab-jjmr Vyepti PA   MB
erenumab-aooe Aimovig PA  
fremanezumab-vfrm for migraine prophylaxis Ajovy PD PA  
galcanezumab-gnlm Emgality PD PA  
rimegepant Nurtec PD PA  
ubrogepant Ubrelvy PD PA  
zavegepant Zavzpret PA  

 Headache Therapy – Ergot Alkaloids

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

dihydroergotamine injection PA  
dihydroergotamine nasal spray Migranal PA   A90
ergotamine / caffeine suppository PA   A90

 Headache Therapy – Serotonin Receptor Agents

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

almotriptan PA   A90
eletriptan Relpax PA   A90
frovatriptan Frova PA   BP, A90
lasmiditan Reyvow PA  
naratriptan PA   - > 18 units/30 days A90
rizatriptan orally disintegrating tablet Maxalt MLT PA   - > 18 units/30 days # , A90
rizatriptan tablet Maxalt PA   - > 18 units/30 days # , A90
sumatriptan / naproxen PA   A90
sumatriptan 10 mg nasal spray Tosymra PA  
sumatriptan 5 mg, 20 mg nasal spray Imitrex PA   - > 18 units/30 days # , A90
sumatriptan injection-Imitrex Imitrex PA  
sumatriptan injection-Zembrace Zembrace PA  
sumatriptan tablet Imitrex PA   - > 18 units/30 days # , A90
zolmitriptan nasal spray Zomig PA   A90
zolmitriptan orally disintegrating tablet PA   A90
zolmitriptan tablet Zomig PA   - > 18 units/30 days # , A90
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. PA is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
PD Preferred Drug. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class.
 
MB This drug is available through the health care professional who administers the drug or in an outpatient or inpatient hospital setting. MassHealth does not pay for this drug to be dispensed through the retail pharmacy. If listed, PA does not apply through the hospital outpatient and inpatient settings. Please refer to 130 CMR 433.408 for PA requirements for other health care professionals. Notwithstanding the above, this drug may be an exception to the unified pharmacy policy; please refer to respective MassHealth Accountable Care Partnership Plans (ACPPs) and Managed Care Organizations (MCOs) for PA status and criteria, if applicable.
 
A90 Allowable 90-day supply. Dispensing in up to a 90-day supply is allowed. May not include all strengths or formulations. Quantity limits and other restrictions may apply.
 

II. Therapeutic Uses

FDA-approved, for example:

  • acute treatment of migraine (all triptans, dihydroergotamine injection, dihydroergotamine nasal spray, ergotamine/caffeine suppository, Nurtec, Reyvow, Ubrelvy, Zavzpret)
  • cluster headache (dihydroergotamine injection, sumatriptan injection)
  • chronic tension-type headache (butalbital agents)
  • episodic cluster headache (Emgality)
  • migraine prophylaxis (Aimovig, Ajovy, Emgality, Nurtec, Qulipta, Vyepti)
  • vascular headache (ergotamine/caffeine suppository)

Triptans are NOT intended for prophylactic therapy of migraines.

Non-FDA-approved, for example:

  • cluster headache (all triptans except sumatriptan injection, dihydroergotamine nasal spray, ergotamine/caffeine suppository, Reyvow)
  • cyclic vomiting syndrome (sumatriptan 5 mg, 20 mg nasal spray, sumatriptan injection)
  • migraine headache (butalbital agents)
  • vascular headache (all triptans, dihydroergotamine injection, dihydroergotamine nasal spray, Reyvow)

Note: The above lists may not include all FDA-approved and non-FDA approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • Dispensing in a 90-day supply of medication may be mandated or allowable for agents in this therapeutic class (designated by M90 or A90, respectively, in the Drug Notes section above). Applicable quantity limits are described below as units per day, per month, per 28 days, or as clinically appropriate, and may be extrapolated for fills of longer day supply.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply depending upon diagnosis and/or requested medication (see below). Other factors, including rebate and FDA-approval status, may change independently of scheduled MassHealth updates, which may result in additional restrictions.

  

Aimovig, Ajovy, Emgality

  • Documentation of all of the following is required for migraine prophylaxis:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • appropriate dosing; and
    • migraine frequency ≥ four days per month; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: atenolol, metoprolol, nadolol, propranolol, timolol; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: topiramate,  tricyclic antidepressant, valproic acid, venlafaxine; and 
    • for Aimovig, inadequate response or adverse reaction to one or contraindication to all of the following: Ajovy, Emgality.
  • Documentation of the following is required for Emgality for cluster headache:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • appropriate dosing.
  • Documentation of the following is required for recertification of Emgality for cluster headache:
    • the member is still actively having a cluster headache; and
    • the member has been initiated on prophylactic therapy for the cluster headache; or
    • clinical rationale why prophylactic therapy is not appropriate.

   

almotriptan ( ≤ 18 units/30 days), eletriptan ( ≤ 18 units/30 days), and frovatriptan ( ≤ 18 units/30 days)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • for almotriptan, member is ≥ 12 years of age; or
      • for eletriptan or frovatriptan, member is ≥ 18 years of age; and
    • inadequate response or adverse reaction to two or contraindication to all of the following: rizatriptan tablets or orally disintegrating tablets (ODTs), sumatriptan tablets, zolmitriptan tablets.

SmartPA: Claims for ≤ 18 units/30 days of almotriptan tablets will usually process at the pharmacy without a PA request if there is a history of paid MassHealth pharmacy claims for at least two different oral triptan agents available without PA within quantity limits (sumatriptan tablets, rizatriptan ODTs or tablets, zolmitriptan tablets) and the member is ≥ 12 years of age.

SmartPA: Claims for ≤ 18 units/30 days of eletriptan or frovatriptan, will usually process at the pharmacy without a PA request if there is a history of paid MassHealth pharmacy claims for at least two different oral triptan agents available without PA within quantity limits (naratriptan, sumatriptan tablets, rizatriptan ODTs or tablets, zolmitriptan tablets) and the member is ≥ 18 years of age.

 

almotriptan ( > 18 units/30 days), eletriptan ( > 18 units/30 days), and frovatriptan ( > 18 units/30 days)

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Requests will be evaluated on a case-by-case basis, taking into account the member's headache frequency, documentation of neurologist consultation, and prophylactic regimen.

  

Brand name Imitrex 5 mg, 20 mg nasal spray, Imitrex tablet, Maxalt MLT and tablet, and Zomig tablet ( ≤ 18 units/30 days)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response or adverse reaction to the generic equivalent of the requested agent; and
    • inadequate response or adverse reaction to all other triptans available without PA.

 

Brand name Imitrex 5 mg, 20 mg nasal spray, Imitrex tablet, Maxalt MLT and tablet, and Zomig tablet ( > 18 units/30 days)

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

  

butalbital/acetaminophen/caffeine solution ( ≤ ten mL/day)

Please refer to additional criteria if request is for members < 18 years of age and/or for quantities exceeding ten mL/day.

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical condition in which member is not able to swallow solid oral dosage formulations; or
    • clinical rationale why conventional dosage formulations cannot be used.

 

butalbital/aspirin/caffeine capsule and butalbital 50 mg/acetaminophen 325 mg/caffeine 40 mg capsule ( ≤ 20 units/30 days)

Please refer to additional criteria if request is for members < 18 years of age and/or for quantities exceeding 20 units/30 days.

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to butalbital 50 mg/acetaminophen 325 mg/caffeine 40 mg tablets.

  

butalbital-containing agents (formulations that require PA for all quantities, excluding solution formulations and butalbital/aspirin/caffeine capsule) ( ≤ 20 units/30 days)  

Please refer to additional criteria if request is for members < 18 years of age and/or for quantities exceeding 20 units/30 days.

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • clinical rationale for the requested formulation instead of formulations available without PA within quantity limits.

 

butalbital-containing agents exceeding quantity limits ( > 20 units/30 days or > ten mL/day)

For all requests, individual drug PA criteria must be met first where applicable.

  • Documentation of the following is required for a diagnosis of tension headache:
    • appropriate diagnosis; and
    • headache frequency; and
    • current prophylactic regimen; and
    • prescriber is a neurologist or neurology consult notes are provided; and
    • inadequate response or adverse reaction to three or contraindication to all of the following: NSAIDs, acetaminophen, aspirin, acetaminophen/caffeine, and acetaminophen/aspirin/caffeine.
  • Documentation of the following is required for a diagnosis of migraine headache:
    • appropriate diagnosis; and
    • headache frequency; and
    • current prophylactic regimen; and
    • prescriber is a neurologist or neurology consult notes are provided; and
    • inadequate response or adverse reaction to two or contraindication to all triptans; and
    • inadequate response or adverse reaction to two or contraindication to all of the following: NSAIDs, acetaminophen, aspirin, acetaminophen/caffeine, acetaminophen/aspirin/caffeine, and ergot alkaloid; and
    • inadequate response or adverse reaction to one or contraindication to all oral CGRP inhibitors.

 

butalbital-containing agents for members < 18 years of age 

For all requests, individual drug PA criteria must be met first where applicable.

  • Documentation of the following is required for a diagnosis of tension headache:
    • appropriate diagnosis; and
    • headache frequency; and
    • current prophylactic regimen if member experiences more than four headaches per month or headaches that last longer than 12 hours; and
    • prescriber is a neurologist or neurology consult notes are provided that support the use of a butalbital-containing agent; and
    • inadequate response, adverse reaction, or contraindication to all of the following: NSAIDs, acetaminophen, aspirin, acetaminophen/caffeine, acetaminophen/aspirin/caffeine.
  • Documentation of the following is required for a diagnosis of migraine headache:
    • appropriate diagnosis; and
    • headache frequency; and
    • current prophylactic regimen if member experiences more than four headaches per month or headaches that last longer than 12 hours; and
    • prescriber is a neurologist or consult notes from a neurologist are provided that support the use of a butalbital-containing agent; and
    • inadequate response or adverse reaction to two or contraindication to all triptans; and
    • inadequate response, adverse reaction, or contraindication to all of the following: NSAIDs, acetaminophen, aspirin, acetaminophen/caffeine, acetaminophen/aspirin/caffeine. 

    

codeine-containing products for members < 12 years of age

For all requests, individual drug PA criteria and/or butalbital-containing agents age restriction criteria must be met first where applicable.

  • Documentation of one of the following is required:
    • CYP2D6 genotyping confirms member is not an ultra-rapid CYP2D6 metabolizer; or 
    • member has previously utilized a codeine-containing product without adverse effect that prevents repeat use. 

 

dihydroergotamine injection

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the requested formulation as noted by one of the following:
      • cluster headache; or
      • nausea or vomiting with migraine; and
    • inadequate response, adverse reaction, or contraindication to sumatriptan injection.

 

dihydroergotamine nasal spray (generic Migranal)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to both of the following: sumatriptan nasal spray, zolmitriptan nasal spray.

 

dihydroergotamine nasal spray (generic Migranal) 

  • Documentation of the following is required:
    • for all requests, individual drug PA criteria must be met first where applicable; and
    • headache frequency; and
    • neurology consultation should be provided if headache frequency is > 15 headaches/30 days; and
    • member is currently on a prophylactic regimen.

   

ergotamine/caffeine suppository

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the requested formulation as noted by nausea or vomiting with migraine; and
    • inadequate response, adverse reaction, or contraindication to sumatriptan nasal spray; and
    • requested quantity is ≤ 18 suppositories/30 days.

   

naratriptan, rizatriptan ODT and tablet, sumatriptan 5 mg, 20 mg nasal spray, sumatriptan tablet, and zolmitriptan tablet ( > 18 units/30 days)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • for sumatriptan 5 mg, 20 mg nasal spray, member is ≥ 6 years of age; and
    • requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

 

Nurtec

  • Documentation of the following is required for a diagnosis of acute treatment of migraine:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • inadequate response or adverse drug reaction to two or contraindication to all oral triptans; and
    • requested quantity is ≤ 16 units/30 days.
  • Documentation of all of the following is required for a diagnosis of migraine prophylaxis:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • migraine frequency ≥ four days per month; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: Aimovig, Ajovy, Emgality; and
    • requested quantity is ≤ 16 units/30 days.

   

Ubrelvy ( ≤ 16 units/30 days)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • inadequate response or adverse drug reaction to two or contraindication to all oral triptans.

 

Nurtec and Ubrelvy ( > 16 units/30 days)

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency and prophylactic regimen.

    

Qulipta

  • Documentation of all of the following is required for a diagnosis of migraine prophylaxis:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • migraine frequency ≥ four days per month; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: atenolol, metoprolol, nadolol, propranolol, timolol; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: Botox, topiramate, tricyclic antidepressant, valproic acid, venlafaxine; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: Aimovig, Ajovy, Emgality; and
    • requested quantity is ≤ one unit/day.

 

Reyvow ( ≤ eight units/30 days)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • inadequate response or adverse reaction to two different triptan agents or contraindication to all oral triptans; and
    • prescriber is a neurologist or consult from a neurologist is provided. 

  

Reyvow ( > eight units/30 days)

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

 

 

sumatriptan injection ( ≤ 18 injections/30 days)

  • Documentation of the following is required for a diagnosis of acute treatment of migraine, cluster headache, vascular headache:
    • appropriate diagnosis; and
    • medical necessity for the requested formulation as noted by one of the following:
      • cluster headache; or
      • nausea or vomiting with migraine.


  • Documentation of the following is required for a diagnosis of acute treatment of cyclic vomiting syndrome:
    • appropriate diagnosis.

 

sumatriptan injection ( > 18 injections/30 days) and zolmitriptan nasal spray ( > 18 units/30 days)

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

  

sumatriptan/naproxen ( ≤ 18 units/30 days)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two of the following: sumatriptan tablets, rizatriptan ODT or tablets, and zolmitriptan tablets; and
    • medical necessity for the combination product instead of the commercially available separate agents.

 

sumatriptan/naproxen ( > 18 units/30 days)

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

  

Tosymra ( ≤ 18 units/30 days)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the requested formulation as noted by nausea or vomiting with migraine; and
    • inadequate response or adverse reaction to one or contraindication to both of the following:
      • sumatriptan 5 mg or 20 mg nasal spray; or
      • zolmitriptan nasal spray.

 

Tosymra ( > 18 units/30 days)

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

   

Vyepti

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • appropriate dosing; and
    • migraine frequency ≥ four days per month; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: atenolol, metoprolol, nadolol, propranolol, timolol; and
    • inadequate response or adverse reaction to one or contraindication to all of the following: Botox, topiramate, tricyclic antidepressant, valproic acid, venlafaxine;  and
    • inadequate response or adverse reaction to one or contraindication to all of the following: Aimovig, Ajovy, Emgality.

 

Zavzpret ( ≤ 12 units/30 days)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • inadequate response or adverse reaction to two or contraindication to all triptan nasal sprays; and
    • medical necessity for the requested formulation as noted by nausea or vomiting with migraine.

Zavzpret ( > 12 units/30 days)

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

 

Zembrace ( ≤ 36 units/30 days)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the requested formulation as noted by nausea or vomiting with migraine; and
    • inadequate response or adverse reaction to sumatriptan injection (generic Imitrex).

 

Zembrace ( > 36 units/30 days)

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

 

zolmitriptan ODT ( ≤ 18 units/30 days)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two of the following: rizatriptan ODT or tablets, sumatriptan tablets, and zolmitriptan tablets; or
    • both of the following:
      • medical necessity for the requested formulation as noted by nausea or vomiting with migraine; and 
      • inadequate response or adverse reaction to rizatriptan ODT.

 

zolmitriptan ODT ( > 18 units/30 days)

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Requests will be evaluated on a case-by-case basis, taking into account the member’s headache frequency, documentation of neurologist consultation, and prophylactic regimen.

   

zolmitriptan nasal spray ( < 18 units/30 days)

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical necessity for the requested formulation as noted by nausea or vomiting with migraine.

 

 Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.


Original Effective Date: 03/2002

Last Revised Date: 05/2024


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Last updated 05/16/24

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