Washington prescribers request coverage of a CGRP receptor antagonist for chronic migraine accepted on a workers' compensation claim with this one-page form. Initial requests must meet all criteria: migraine causally related to the injury, a 3-month headache diary, International Headache Society chronic migraine criteria, three failed prophylaxis drugs from two classes, managed medication overuse and a time-limited rehabilitative plan.
The prescribing provider completes section 1, then section 2 for an initial request or section 3 for continued coverage, and signs section 4.
Download the current version from the source each time; forms change without notice.
Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist for Treatment of Chronic Migraine
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For the initial course, all must be met: chronic migraine causally related to the industrial injury, a headache diary of at least 3 months, IHS chronic migraine criteria, at least three prophylaxis drugs from two classes tried, managed medication overuse, and use as part of a time-limited rehabilitative plan.
Complete section 3: whether the drug was well tolerated during the 90-day trial, whether headache days dropped at least 50% from baseline (attach the diary), and whether the trial brought rehabilitative benefit, such as participation in vocational rehabilitation or return to work.