CurrentAvMedPolicy N/A

Migraine Treatment: Non-injectable drugs — Pharmacy Prior Authorization/Step-Edit

Defines prior authorization, step-edit, and clinical criteria for coverage of selected non-injectable migraine medications for AvMed members; applies to prescribers requesting these outpatient pharmacy products.

Policy Summary

PayerAvMed

PolicyMigraine Treatment: Non-injectable drugs — Pharmacy Prior Authorization/Step-Edit

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateNov 21, 2024

Key ActionPrescriber must complete the PA/step-edit form, attest to meeting clinical criteria, and provide verification of prior therapy trials or contraindications as specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6drugs listed on form

18+min age for approval

variesquantity limits specified

prior trials requiredstep edits

faxsubmission method

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Authorization Criteria (Acute and Preventive Migraine — all criteria must be met)

Covered when ALL of the following applicable sets of conditions are met for the selected diagnosis and drug:

Age and general attestation: Member must be 18 years of age or older; provider attests to all clinical criteria for the applicable diagnosisage >= 18

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Diagnosis: Acute Migraine - triptan requirement or contraindication: For Acute Migraine, member must meet ONE of: failed (defined as ≥ 2 attacks) at least TWO triptans taken at maximum recommended doses; intolerance to triptan therapy; OR have at least one cardiovascular or non-cardiovascular contraindication to triptan therapy (ischemic CAD including angina/MI/silent ischemia/coronary vasospasm, history of stroke or TIA, peripheral vascular disease, ischemic bowel disease, uncontrolled hypertension)failed >=2 attacks on >=2 triptans

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Acute-specific requirements and safety attestations: For Reyvow, Ubrelvy, and Zavzpret requests: member must have trial and failure of Nurtec ODT (verified via pharmacy paid claims or chart notes). For Nurtec ODT or Ubrelvy requests: provider must attest member does NOT have CrCl < 15 mL/min, is NOT using a strong CYP3A4 inhibitor or inducer, and does NOT have severe hepatic impairment (Child-Pugh C). For Reyvow requests: member has agreed not to drive or operate machinery for at least 8 hours after each dose. Requested medication will NOT be used in combination with another oral CGRP inhibitor.agent-specific safety checks

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Diagnosis: Preventive Migraine criteria: Applies to Nurtec ODT and Qulipta only: member must have Chronic or Episodic Migraine with ≥ 4 migraine headaches per month AND must have failed a 2-month trial of at least one medication from TWO different migraine prophylactic classes (anticonvulsants, beta blockers, antidepressants, candesartan [requires PA], or CGRP inhibitors) per guideline-supported evidence. Provider must attest to renal/interaction/hepatic safety checks and that Nurtec/Qulipta will not be used in combination with injectable CGRPs or Botox except as allowed under concurrent-use criteria.>=4 migraines/month; failed 2-month trials of 2 classes

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Concurrent CGRP inhibitor with Botox criteria: For requests for concurrent use of CGRP inhibitors with Botox for prevention: member must have Chronic or Episodic Migraine and continue to experience ≥ 4 migraine headache days per month after prior prophylactic trials; member must have had inadequate response to a 2-month trial of at least one medication from two different prophylactic classes and also meet one of: inadequate response to a 2-month trial with an injectable CGRP inhibitor or an oral CGRP inhibitor indicated for prevention, OR inadequate response to a 6-month trial (2 injection cycles) of Botox. Verification via chart notes and/or pharmacy paid claims is required.failed injectable CGRP or Botox per durations

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Use of samples to initiate therapy does not meet step edit/prior authorization criteria. Providers must document prior therapies via pharmacy paid claims or submitted chart notes; sample products alone are insufficient to satisfy required trial-and-failure documentation and may result in denial of the request.

Provider Submission Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for migraine non-injectable therapies listed on this form. Submit completed pharmacy prior authorization/step-edit request with prescriber signature. Incomplete, incorrect, or illegible information (including missing phone/fax) may delay or deny the authorization.

Fax completed form to 1-305-671-0200
Prescriber signature required (preprinted stamps not valid)
Ensure phone and fax numbers are provided and legible

Step Therapy

Step Therapy and Required Prior Trials

Step therapy requirements and prior trials must be documented. Preferred agents (Nurtec ODT, Qulipta) should be tried first when applicable; non-preferred agents require documented failure of preferred options per criteria below.

For Acute Migraine: member must have failed ≥2 triptans (≥2 attacks) or have intolerance/contraindication to triptans.
For Reyvow, Ubrelvy, Zavzpret: member must have tried and failed preferred Nurtec ODT (verified by pharmacy paid claims or chart notes).
For Preventive Migraine (Nurtec ODT, Qulipta): member must have failed a 2-month trial of at least one medication from TWO different prophylactic classes (anticonvulsants, beta blockers, antidepressants, candesartan*, or prior CGRP inhibitors).
Prior use of samples does NOT satisfy step edit/ prior trial requirements.
*Candesartan requires prior authorization.

Documentation Required

Required Patient and Prescriber Information and Supporting Documentation

Provide complete member, prescriber, and drug information. Missing or incomplete fields may delay processing or lead to denial.

Member Name, AvMed ID, Date of Birth
Prescriber Name, Prescriber Signature (hand-signed), NPI
Office contact name, phone number, fax number
Drug name/form/strength, dosing schedule, length of therapy, quantity requested
Diagnosis and ICD code (if applicable), weight and date weight obtained (if applicable)
Documentation supporting prior trials/failures (pharmacy paid claims or chart notes), relevant lab results/diagnostics/chart notes

Denial Risk

Incomplete Documentation Triggers Delay/Denial

Incomplete documentation or lack of required prior trials may result in delay or denial. Use pharmacy paid claims or chart notes to verify prior therapy; absence of verification may cause request denial.

Samples used to start therapy do not meet prior trial requirements
Requests for concurrent use of CGRP inhibitors with Botox require documentation of prior trials and continued migraine frequency
Verify contraindications/intolerances and attestations (e.g., CrCl, CYP3A4 interactions, hepatic impairment, driving restrictions for Reyvow)

Acute and Preventive Migraine Definitions

inv-09: Acute Migraine

Definition (Acute Migraine) - triptan requirementFor Acute Migraine, member must meet ONE of: failed (≥2 attacks) at least TWO triptans at maximum recommended doses

Acute alternative: intoleranceProvider may attest member has an intolerance to triptan therapy instead of triptan trials

Acute alternative: contraindicationMember may qualify if they have ≥1 cardiovascular or non-cardiovascular contraindication to triptans (e.g., ischemic CAD, stroke/TIA, peripheral vascular disease, ischemic bowel disease, uncontrolled hypertension)

Agent-specific acute requirementFor Reyvow, Ubrelvy, and Zavzpret requests, member must have trial and failure of Nurtec ODT (verified via claims or chart notes)

inv-10: Preventive Migraine

Preventive migraine definitionMember must have ≥4 migraine headaches per month (applies to Nurtec ODT and Qulipta only)

Required prior prophylactic trialsMember must have failed a 2-month trial of at least one medication from TWO different preventive migraine classes (anticonvulsants, beta blockers, antidepressants, candesartan*, or CGRP inhibitors)

Candesartan noteUse of candesartan (an ARB) requires prior authorization

Concurrent therapy restrictionProvider must attest Nurtec/Qulipta will not be used with injectable CGRPs or Botox except under specified combined-use criteria

Initial Therapy Requirements

Initial therapy requirements

Initial approval requires meeting diagnosis-specific prior trial or contraindication criteria and attestation of required safety checks.

Acute initial therapy: Meet acute migraine criteria: age >=18 and ONE of triptan failure/intolerance or documented contraindication to triptans; for Reyvow, Ubrelvy, and Zavzpret requests must have trial and failure of Nurtec ODT (verified by claims or chart notes). Provider must attest to agent-specific safety checks (CrCl, CYP3A4 interactions, hepatic impairment) and that medication will not be used with another oral CGRP inhibitor.

Preventive initial therapy: For Nurtec ODT or Qulipta preventive use: member must have >=4 migraine headaches/month and failed a 2-month trial of at least one medication from TWO different preventive migraine drug classes (anticonvulsants, beta blockers, antidepressants, candesartan [PA required], or CGRP inhibitors). Provider must attest to renal function, CYP3A4 interaction, and hepatic impairment checks and that Nurtec/Qulipta will not be used in combination with injectable CGRPs or Botox unless concurrent-use criteria are met.

Step Therapy Requirements

Requirement	Details / Evidence
Step therapy requirement	Member must try and fail preferred agent(s) prior to coverage of listed non-preferred agents. Specifically, Reyvow, Ubrelvy, and Zavzpret requests require trial and failure of Nurtec ODT (verified via pharmacy paid claims or chart notes). (See policy step-edit language)
Diagnosis-specific prior therapy	For Acute Migraine, member must meet one of: failed (≥2 attacks) at least two triptans at maximum recommended doses; intolerance to triptans; or have at least one listed triptan contraindication (ischemic CAD, stroke/TIA, peripheral vascular disease, ischemic bowel disease, uncontrolled hypertension). Certain agent-specific safety attestations also apply (CrCl, CYP3A4 interactions, hepatic impairment).
Verification and documentation	Previous therapies will be verified through pharmacy paid claims or submitted chart notes. Use of samples to initiate therapy does not meet step edit/prior authorization criteria.

Quantity Limits by Drug

inv-14: Nurtec ODT — Acute: 8 tablets per 30 days; Preventive: 16 tablets per 30 days

Acute quantity limitNurtec ODT: 8 tablets per 30 days

Preventive quantity limitNurtec ODT: 16 tablets per 30 days

Acute dosing summaryNurtec ODT acute dose: 75 mg as single dose; max 75 mg/24 hours

inv-15: Ubrelvy — 10 tablets per 30 days

Quantity limitUbrelvy: 10 tablets per 30 days

Dosing noteUbrelvy acute dose: 50–100 mg single dose; may repeat once after ≥2 hours; maximum 200 mg per 24 hours

inv-16: Reyvow — 4 tablets per 30 days

Quantity limitReyvow: 4 tablets per 30 days

Dosing noteReyvow acute dose: 50–100 mg as a single dose; maximum of 1 dose in 24 hours

inv-17: Qulipta — 30 tablets per 30 days

Quantity limitQulipta: 30 tablets per 30 days

Dosing noteQulipta preventive dose: 10 mg, 30 mg, or 60 mg once daily; maximum 60 mg/day

inv-18: Zavzpret (zavegepant) nasal spray — 1 carton (6 sprays) per 30 days

Quantity limitZavzpret (zavegepant) nasal spray: 1 carton (6 sprays) per 30 days

Dosing noteZavzpret acute dose: 10 mg as a single spray in one nostril; maximum 10 mg/24 hours

Background

This prior authorization form covers both acute and preventive migraine treatment with several non-injectable agents, including small-molecule gepants (e.g., rimegepant, atogepant, ubrogepant, zavegepant) and other oral/nasal therapies (e.g., lasmiditan). The form aligns required prior therapies, contraindications, and safety checks (renal function, hepatic impairment, and drug–drug interactions) with guideline-supported classes and specifies quantity limits and dosing parameters for each listed agent.

Providers should use the form to attest to the member's diagnosis (acute or preventive), document prior trial(s) or contraindications to triptans and prophylactic classes when applicable, and supply supporting documentation (claims or chart notes) to verify prior therapies and safety considerations before the requested non-injectable migraine product will be authorized.