CurrentCignaPolicy IP0148

Migraine – Ubrelvy - (IP0148)

Prior authorization policy for coverage of Ubrelvy (ubrogepant tablets) for the acute treatment of migraine in adults under Cigna benefit plans, specifying medical necessity criteria, exclusions, and approval duration.

Policy Summary

PayerCigna

PolicyMigraine – Ubrelvy - (IP0148)

Policy CodePolicy IP0148

Change TypeMaterial updates to contraindication wording and removal of concurrent-use exclusion

Effective Date

Next Review Date

Key ActionPrior Authorization is required; approve for 1 year when criteria met and document either a trial of at least one triptan or a prescriber-documented contraindication to triptans.

SourceLink

POLICY UPDATE CHANGES

Removed 'Concurrent use (for example, during the same time period) of two CGRP inhibitors indicated for the acute treatment of migraine (for example Nurtec ODT and Ubrelvy).' from Conditions Not Covered.

Updated the contraindication to triptan(s) statement in the Migraine, Acute Treatment section.

Annual Revision dated 04/15/2026 indicated no criteria changes.

Annual Revision dated 05/15/2025 noted no criteria changes.

1Covered Indication (acute migraine)

1 yearApproval Duration

≥18Minimum Age

Coverage Summary

Scope: Prior authorization policy for coverage of Ubrelvy (ubrogepant tablets) for the acute treatment of migraine in adults under Cigna benefit plans, specifying medical necessity criteria, exclusions, and approval duration.

Coverage stance: Covered with criteria for the FDA-approved indication: Ubrelvy (ubrogepant) is indicated for the acute treatment of migraine with or without aura in adults. It is not indicated for preventive treatment of migraine, and triptans are considered first-line for many acute migraine attacks.

FDA-Approved Indication: Migraine, Acute Treatment

Approve for 1 year if the patient meets BOTH of the following (A and B):

ALL of the following

ALL of the following
- Patient is ≥ 18 years of age
  Age requirement
- ONE of
  - Patient has tried at least one triptan therapy
    Prior trial requirement
  - ALL of the following
    History of coronary artery disease
    Cardiac accessory conduction pathway disorders
    History of stroke, transient ischemic attack, or hemiplegic or basilar migraine
    Peripheral vascular disease
    Ischemic bowel disease
    Uncontrolled hypertension
    Severe hepatic impairment

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Conditions Not Covered

Ubrelvy for any other use is considered not medically necessary.

Use of Ubrelvy for indications other than acute treatment of migraine in adults

Provider Actions

Prior Authorization

Prior authorization required

Prior authorization is required for benefit coverage of Ubrelvy. Approvals are provided for 1 year when the policy criteria are met.

Documentation Required

Documentation of prior triptan trial or contraindication

Provider must document either a trial of at least one triptan or a prescriber-documented contraindication to triptan(s). Examples of contraindications include history of coronary artery disease; cardiac accessory conduction pathway disorders; history of stroke, transient ischemic attack, or hemiplegic or basilar migraine; peripheral vascular disease; ischemic bowel disease; uncontrolled hypertension; or severe hepatic impairment.

Applicable Codes

Policy identifiersmixed

IP0148

Coverage Policy Number

Background

Background: Ubrelvy (ubrogepant) is an oral calcitonin gene-related peptide (CGRP) receptor antagonist indicated for the acute treatment of migraine headache with or without aura in adults. The drug is not indicated for preventive treatment of migraine.

Triptans (for example, almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) are considered the gold standard/first-line for many moderate to severe acute migraine attacks or for mild to moderate attacks that do not respond to over-the-counter analgesics. This policy is a prior authorization policy under Cigna benefit plans and requires documentation of either a trial of at least one triptan or a prescriber-documented contraindication to triptans for approval.

Quick Policy Facts

Approval Duration1 year

Minimum Age≥ 18

RequirementPrior triptan trial or contraindication

Covered IndicationAcute migraine

Clinical Evidence

No clinical trials or external evidence were supplied in the brief; the FDA-approved indication and prescribing information are the primary basis for this coverage policy.

Revision History

06/01/2024annual_review

Annual Review dated 06/01/2024 removed the concurrent-use exclusion for two acute CGRP inhibitors. Removed 'Concurrent use (for example, during the same time period) of two CGRP inhibitors indicated for the acute treatment of migraine (for example Nurtec ODT and Ubrelvy).' from Conditions Not Covered.

02/01/2026selected_revision

Selected Revision dated 02/01/2026 modified wording regarding contraindications to triptans. Updated the contraindication to triptan(s) statement in the Migraine, Acute Treatment section.

05/15/2025annual_revision

Annual Revision dated 05/15/2025 noted no criteria changes.