Calcitonin gene-related peptide (CGRP) receptor agents
Customize your policy alerts
Sign up for allcareadvantage Policy 083.5 alerts
Get alerted when Policy 083.5 changes without checking for updates manually.
Monitor payer policy activity
Defines prior authorization criteria for coverage of formulary calcitonin gene-related peptide (CGRP) receptor agents for prevention and acute treatment of migraine for AllCare Advantage members.
Coverage Criteria for CGRP Receptor Agents
Initial Therapy
Covered when the following sequential criteria are met according to the flow in the policy:
Continuation Therapy
Renewal coverage requires both initial criteria and evidence of benefit:
Requests for members under 18 years of age are excluded and will be denied. The policy’s initial criteria explicitly require that the member be 18 years of age or older; failure to meet this age threshold results in denial.
Requests that do not document required prior trials will be denied. For acute treatment requests, documentation must show an adequate trial of two triptans (≥30 days each) or a documented contraindication to triptans; lacking this documentation leads to denial. For preventative treatment requests, documentation must show failure of at least one oral prophylactic agent (e.g., topiramate, propranolol); failure to document this prior trial results in denial.
Coding and Trial Duration
Provider Actions and Documentation Requirements
Prior authorization required; approval lengths
Prior authorization is required for all CGRP receptor agents. Initial approvals are for up to 6 months; renewal approvals are for up to 12 months.
Step therapy: required prior trials
Step therapy requires documented prior trials of two triptans for acute therapy (each trial ≥ 30 days) unless there is a documented contraindication. For preventative therapy, failure of at least one oral prophylactic agent is required; non-preferred agents require failure or contraindication to preferred formulary agents.
- Each triptan trial must be at least 30 days.
- For acute requests, also document failure of at least one oral non-triptan agent (e.g., NSAIDs, APAP, or APAP/ASA/caffeine).
- For preventative requests, document failure of at least one oral prophylactic (e.g., topiramate, propranolol).
- Non-preferred agents: document failure or contraindication to preferred formulary agent(s).
Required documentation to support request
Documentation must confirm the member is 18 years of age or older, document adequate trials of two triptans (or a contraindication to triptans), and for prophylaxis requests document failure of at least one oral prophylactic agent; for non-preferred agents include documentation of failure or contraindication to preferred agents.
- Record member age (must be ≥ 18).
- Document each triptan trial duration (≥ 30 days) or a documented contraindication to triptans.
- For preventative requests, document failure of at least one oral prophylactic (e.g., topiramate, propranolol).
- For non-preferred agents, include prior failure or contraindication to preferred formulary agent(s).
Denial risks for missing criteria
Requests for members under 18 years of age must be denied. Requests that do not document required prior trials (two triptans of ≥30 days each, or documented contraindication) or, for preventative therapy, failure of at least one oral prophylactic agent will be denied.
- Member < 18 years — deny.
- Incomplete documentation of two adequate triptan trials (≥ 30 days each) or lack of documented contraindication to triptans — deny.
- Preventative requests without documented failure of at least one oral prophylactic agent — deny.
Definitions and FDA Indications
Background
Background: Calcitonin gene-related peptide (CGRP) receptor agents are included in this policy for use in migraine management. The policy applies the FDA-approved indication for migraine prophylaxis and also addresses use for acute migraine treatment by defining prior authorization criteria and step-therapy requirements. It references clinical prescribing guidance to support coverage decisions and requires that members meet the policy’s age and prior-trial criteria before approval.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.