Anti-Migraine Criteria
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This policy governs prior authorization for Nurtec ODT, Qulipta, and Ubrelvy for adult Medicaid beneficiaries, including initial therapy, continuation therapy, prior-trial, documentation, and dosing requirements.
No material clinical or coverage changes in this revision.
Drug-Specific Coverage Criteria
Nurtec ODT — Episodic Migraine Prophylaxis
Covered when ALL of the following are met:
ALL of the following
- Patient is at least 18 years of age.≥ 18 years
- Patient is using Nurtec ODT for episodic migraine prophylaxis.
- Patient has had a previous trial with inadequate response, intolerable adverse reaction, or contraindication to Aimovig, Ajovy, or Emgality.
Documentation required.
Nurtec ODT — Acute Migraine Treatment
Covered when ALL of the following are met:
ALL of the following
- Patient is at least 18 years of age.≥ 18 years
- Patient is using Nurtec ODT for the acute treatment of migraine.
- Patient has had a previous trial with a preferred triptan.
Documentation required.
Qulipta — Episodic or Chronic Migraine Prophylaxis
Covered when ALL of the following are met:
ALL of the following
- Patient is at least 18 years of age.≥ 18 years
- Patient is using Qulipta for episodic or chronic migraine prophylaxis.
- Patient has had a previous trial with inadequate response, intolerable adverse reaction, or contraindication to Aimovig, Ajovy, or Emgality.
Documentation required.
Ubrelvy — Acute Migraine Treatment
Covered when ALL of the following are met:
ALL of the following
- Patient is at least 18 years of age.≥ 18 years
- Patient is using Ubrelvy for the acute treatment of migraine.
- Patient has had a previous trial with a preferred triptan.
Documentation required.
Continuation of Therapy
Continuation therapy is covered when ALL of the following are met:
ALL of the following
- Patient met the initial review criteria.
- Documentation of improved clinical response is provided.
Documentation required.
- Patient has not experienced any treatment-restricting adverse effects.
- Dosing is appropriate according to product labeling or is supported by compendia.
Authorization and Documentation Requirements
Prior Authorization Required
Prior authorization is required for Anti-Migraine Criteria coverage. Authorization is issued for 1 year when the patient is at least 18 years of age and the applicable drug-specific eligibility criteria are met.
- Minimum age: 18 years.
- Nurtec ODT: episodic migraine prophylaxis or acute treatment of migraine.
- Qulipta: episodic or chronic migraine prophylaxis.
- Ubrelvy: acute treatment of migraine.
Required Prior Therapy
The applicable prior-therapy requirement must be satisfied for the requested use. Prophylaxis requests require a prior trial of Aimovig, Ajovy, or Emgality; acute-treatment requests require a prior trial of a preferred Triptan.
- Nurtec ODT prophylaxis and Qulipta prophylaxis: prior Aimovig, Ajovy, or Emgality trial with inadequate response, intolerable adverse reaction, or contraindication.
- Nurtec ODT and Ubrelvy for acute migraine treatment: prior trial with a preferred Triptan.
- Qulipta may be used for episodic or chronic migraine prophylaxis.
Document Prior Treatment History
Document the required prior treatment history in the patient record and submit it with the authorization request. Documentation must establish the applicable prior trial and the resulting inadequate response, intolerable adverse reaction, or contraindication, or the prior preferred Triptan trial for acute-treatment requests.
- For prophylaxis: identify the trial of Aimovig, Ajovy, or Emgality and document inadequate response, intolerable adverse reaction, or contraindication.
- For acute migraine treatment: identify the prior trial with a preferred Triptan.
- Documentation is required for the applicable prior-treatment criterion.
Continuation Documentation Required
For continuation of therapy, document that the patient met the initial review criteria, has improved clinical response, has not experienced treatment-restricting adverse effects, and is receiving appropriate dosing.
- Document that initial review criteria were met.
- Document improved clinical response.
- Document absence of treatment-restricting adverse effects.
- Confirm dosing is appropriate according to labeling or supported by compendia.
Policy Scope and Clinical Context
This policy establishes prior authorization criteria for adult migraine treatment with Nurtec ODT (rimegepant), Qulipta (atogepant), and Ubrelvy (ubrogepant). Nurtec ODT and Qulipta are addressed for migraine prevention, including episodic or chronic migraine prophylaxis where applicable, while Nurtec ODT and Ubrelvy are addressed for the acute treatment of migraine.
Initial Therapy
Initial Therapy
Initial therapy requires the patient to be at least 18 years of age and to meet one applicable drug-specific indication and prior-treatment pathway:
Initial therapy
- Minimum age: Patient is at least 18 years of age.Age ≥18 years
ONE applicable drug-specific pathway
Nurtec ODT prophylaxis
- Patient is using Nurtec ODT for episodic migraine prophylaxis.
- The patient has had a previous trial with inadequate response, intolerable adverse reaction, or contraindication to Aimovig, Ajovy, or Emgality.One qualifying prior therapy or contraindication
Documentation required.
Nurtec ODT acute treatment
- Patient is using Nurtec ODT for the acute treatment of migraine.
- The patient has had a previous trial with a preferred triptan.One previous preferred triptan trial
Documentation required.
Qulipta prophylaxis
- Patient is using Qulipta for episodic or chronic migraine prophylaxis.
- The patient has had a previous trial with inadequate response, intolerable adverse reaction, or contraindication to Aimovig, Ajovy, or Emgality.One qualifying prior therapy or contraindication
Documentation required.
Ubrelvy acute treatment
- Patient is using Ubrelvy for the acute treatment of migraine.
- The patient has had a previous trial with a preferred triptan.One previous preferred triptan trial
Documentation required.
Continuation Therapy
Continuation Therapy
Continuation of therapy requires all of the following conditions:
Continuation therapy
- Patient met initial review criteria.
- Documentation shows improved clinical response.
- Patient has not experienced any treatment-restricting adverse effects.
- Dosing is appropriate according to labeling or is supported by compendia.Per product labeling or supported by compendia
Required Prior Medication Trials
| Step | Required prior therapy | Applies before | Qualifying outcome/documentation |
|---|---|---|---|
| 1 | Trial of Aimovig, Ajovy, or Emgality | Nurtec ODT for episodic migraine prophylaxis; Qulipta for episodic or chronic migraine prophylaxis | Inadequate response, intolerable adverse reaction, or contraindication; documentation required |
| Step | Required prior therapy | Applies before | Documentation |
|---|---|---|---|
| 1 | Trial of a preferred triptan | Nurtec ODT or Ubrelvy for acute migraine treatment | Previous trial required; documentation required |
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