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 generic triptan products:
- 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)
- Submission of medical records (e.g., chart notes) confirming 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 generic triptan products:
- 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
2026-04-21, 2025-12-18, 2025-05-01, 2024-04-24, 2023-05-03, 2022-05-09
References
- Elyxyb Prescribing Information. BioDelivery Sciences International, Inc. Raleigh, NC. September 2021.
Revision History
- 2026-04-21: Annual Review 2026 - Specified triptan products in embedded step criteria without change to clinical intent. Updated NF diagnosis criterion for standard NF format to require medical records. Background updates
- 2025-12-18: no criteria changes, added IL statute operational note
- 2025-05-01: 2025 Annual Review. Background updates only.
- 2024-04-24: 2024 annual review. Background changes.
- 2023-05-03: Annual review - no changes.
- 2022-05-09: New PA program for Elyxyb.
HEALTHY LIVING