CurrentCignaPolicy N/A

Migraine - Other Medications Drug Quantity Management (Per Days)

Cigna Drug Quantity Management policy that governs quantity limits and one-time quantity overrides for acute migraine medications Nurtec ODT (rimegepant ODT), Reyvow (lasmiditan), Ubrelvy (ubrogepant), and Zavzpret (zavegepant) for applicable Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyMigraine - Other Medications Drug Quantity Management (Per Days)

Policy CodePolicy N/A

Change TypeClarified titleno criteria changes

Effective Date

Next Review Date

Key ActionIf the Drug Quantity Management rule is not met at point of service, follow the policy criteria for coverage and apply the specified one-time quantity overrides for strength increases of Reyvow (50 mg → 100 mg) and Ubrelvy (50 mg → 100 mg), documenting clinical need when requesting overrides.

SourceLink

POLICY UPDATE CHANGES

Title of the policy was updated to 'Migraine - Other Medications DQM Policy - Per Days' from 'Migraine - Other Acute Medications DQM Policy - Per Days'.

4drug products covered by this DQM policy

28dquantity window used for retail limits

84dquantity window used for home delivery limits

No changesstatus at last annual revision (2024-12-09)

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When These Acute Migraine Products Are Covered

General Policy Statement

Drug Quantity Management program prevents stockpiling/misuse and approvals are provided when Drug Quantity Management rule is not met; products are covered as medically necessary when the following criteria are met. Any other exception is not medically necessary.

ALL of the following

Policy applies to Nurtec ODT, Reyvow, Ubrelvy, and Zavzpret for acute migraine treatment (Nurtec ODT also has preventive indication).
Quantity limits are applied per chemical entity within the same dosage form; conventional tablets and orally-disintegrating tablets are considered the same dosage form for quantity limits.
If Drug Quantity Management rule is not met at point of service, coverage is determined by the criteria in this policy.

Product-specific Criteria and Overrides

Approvals/overrides for specific situations are limited and defined per product below:

Products with no overrides recommended

Nurtec ODT — No overrides recommended.
Reyvow 50 mg tablets — No overrides recommended.
Ubrelvy 50 mg tablets — No overrides recommended.
Zavzpret 10 mg nasal spray — No overrides recommended.

Products with single one-time strength-increase override

Reyvow 100 mg tablets: If increasing strength within same chemical entity and same dosage form (from Reyvow 50 mg to 100 mg), approve a one-time quantity override for 8 tablets (1 box) at retail or home delivery.

Quantity and safety thresholds

Nurtec ODT monthly safetyNo more than 18 doses in a 30-day period (safety not established beyond)

Reyvow dosing limitNo more than 1 dose per 24 hours; safety of treating an average of more than 4 migraine attacks in 30 days not established

Ubrelvy dosing limitsMaximum 200 mg per 24 hours; safety of treating more than 4 or 8 migraines in a 30-day period not established (policy cites both limits in different contexts)

Zavzpret dosing limitMaximum 10 mg (one spray) per 24 hours; safety of treating more than 8 migraines in a 30-day period not established

Guideline frequencyLimit acute therapy to less than 2 days per week or ≤8 treatment days per month to avoid medication-overuse headache

Drugs Included & Quantity Limits

Drugs included in policyNDC|drug nameCovered

rimegepant (Nurtec ODT)	Orally disintegrating tablet, 75 mg; indicated for acute and preventive treatment (every other day for prevention). Retail max: 16 tablets per 28 days; Home delivery max: 48 tablets per 84 days.
lasmiditan (Reyvow)	Tablets, 50 mg / 100 mg / 200 mg; recommended dosing 50-200 mg as needed, no more than one dose per 24 hours. Retail max (50 mg boxes): 8 tablets per 28 days; Home delivery max: 24 tablets per 84 days. For 100 mg strength an override rule is specified for 8 tablets (one-time quantity override).
ubrogepant (Ubrelvy)	Tablets, 50 mg / 100 mg; recommended dose 50 or 100 mg with optional second dose ≥2 hours later; max 200 mg per 24 hours. Retail max: 20 tablets per 28 days; Home delivery max: 60 tablets per 84 days. For 100 mg strength an override rule is specified for 10 tablets (one-time quantity override).
zavegepant (Zavzpret)	10 mg nasal spray; single spray in one nostril as needed; max 1 spray (10 mg) per 24 hours. Retail max: 12 units per 28 days; Home delivery max: 36 units per 84 days.

Prior Authorization, Documentation, and Denial Guidance

Prior Authorization

Quantity overrides at point of service

If the Drug Quantity Management rule is not met at point of service, coverage will be determined by this policy; one-time quantity overrides are allowed only for strength increases from Reyvow 50 mg → 100 mg and Ubrelvy 50 mg → 100 mg as specified below.

Reyvow 100 mg override: allow one-time 8 tablets
Ubrelvy 100 mg override: allow one-time 10 tablets

Documentation Required

Quantity limit rationale and form

When requesting a designated one-time strength‑increase quantity override, providers should document the clinical need for the override and provide evidence of prior strength or dose changes to support the request.

Clinical Context

These four products — rimegepant (Nurtec ODT), lasmiditan (Reyvow), ubrogepant (Ubrelvy), and zavegepant (Zavzpret) — are small-molecule therapies indicated for the acute treatment of migraine in adults. In addition, Nurtec ODT (rimegepant) also has an FDA-approved indication for the preventive treatment of episodic migraine (every other day dosing for prevention).

Use of acute migraine medications can lead to medication‑overuse headache when taken frequently; such overuse is generally defined in literature as treatment on 10 or more days per month for 3 months or more. Clinical guidance therefore states that acute (abortive) therapies are not intended for regular daily use and that clinicians should limit acute therapy to less than 2 days per week or to ≤ 8 treatment days per month. Patients needing abortive therapy more often should be re‑evaluated for diagnosis and considered for preventive treatment.

This Drug Quantity Management policy applies quantity limits to these chemical entities and dosage forms to help prevent stockpiling, misuse, and overuse. For the purposes of quantity limits, conventional tablets and orally disintegrating tablets are treated as the same dosage form, and the policy’s quantity windows (retail up to 28 days; home delivery up to 84 days) are set to align with the guideline frequency recommendations.

Defined Terms

Definitions

Drug Quantity Management (DQM)Program designed to limit quantity dispensed over a specified time window to prevent stockpiling, misuse, or overuse of acute migraine medications.

Same dosage formFor quantity limits the policy treats conventional tablets and orally-disintegrating tablets as the same dosage form.

Policy Changes

2024-12-09clarifiedLatest

Annual revision; title of the policy was updated to 'Migraine - Other Medications DQM Policy - Per Days' from 'Migraine - Other Acute Medications DQM Policy - Per Days'.