Limited coverage drugs – eptinezumab

100 mg/1mL  and 300 mg/3 mL solution for intravenous infusion

Initial

For the prevention of migraine in adults who meet ALL of the following criteria:

• The patient has a confirmed diagnosis of episodic or chronic migraine defined as:
  • Episodic migraine: migraine headaches on at least 4 days per month and less than 15 headache days per month for more than 3 months
  • Chronic migraine: migraine headaches on at least 8 days per month and headaches for at least 15 days per month for more than 3 months

AND

• The patient has experienced an inadequate response (a minimum three-month trial at optimal dosing) OR intolerance¹ to at least TWO oral prophylactic migraine medications² from TWO different therapeutic classes

AND

• The baseline average number of headache and migraine days per month³ at the time of initial request is provided

AND

• The patient should be under the care of a practitioner who has appropriate experience in the management of patients with migraine headaches

6 months

First renewal

The patient has had a minimum reduction of at least 50% in the average number of migraine days per month³ compared to baseline

6 months

Second and subsequent renewals

The patient has maintained a minimum reduction of at least 50% in the average number of migraine days per month³ compared to baseline

1 year

Anti-seizure medications:

• Divalproex sodium / valproic acid
• Topiramate
• Gabapentin

Serotonin and norepinephrine reuptake inhibitors:

• Duloxetine
• Venlafaxine

Beta-blockers:

• Atenolol
• Metoprolol
• Nadolol
• Propranolol
• Timolol

Tricyclic antidepressants:

• Nortriptyline
• Amitriptyline

Calcium channel blockers:

• Flunarizine
• Verapamil

Renin-angiotensin-aldosterone system inhibitors:

• Candesartan
• Lisinopril

Miscellaneous:

• Pizotifen