CurrentCignaPolicy N/A

Migraine — Other Medications Drug Quantity Management Policy

Defines per-day and per-period drug quantity limits and limited one-time overrides for Nurtec ODT, Reyvow, Ubrelvy, and Zavzpret for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyDrug quantity limits for select acute migraine medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateDec 9, 2024

Key ActionApprove requests when product-specific drug quantity limits are met; if limits are exceeded, perform criteria-based review for one-time overrides.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4medications covered

8–20retail max examples

24–60home delivery max examples

≈2/wkpolicy intent

Coverage Criteria

General coverage and exception rule

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Allowed one-time quantity overrides for strength increases

One-time quantity override criteria for strength increase within same chemical entity and dosage form:

Reyvow 100 mg one-time override: If the strength of the patient's medication is being increased within the same chemical entity and same dosage form (e.g., from Reyvow 50 mg to 100 mg tablets), approve a one-time quantity override for 8 tablets (1 box) at retail or home delivery.8 tablets

Applies only for strength change within same entity and dosage form.

Ubrelvy 100 mg one-time override: If the strength of the patient's medication is being increased within the same chemical entity and same dosage form (e.g., from Ubrelvy 50 mg to 100 mg tablets), approve a one-time quantity override for 10 tablets (1 box) at retail or home delivery.10 tablets

Applies only for strength change within same entity and dosage form.

Products are covered as medically necessary only when the requested quantity does not exceed the specified Drug Quantity Limits for the product and dosing form. Any request that exceeds those limits and does not meet an allowed exception (for example, the one‑time strength increase overrides described elsewhere in this policy) is considered not medically necessary.

Any exception beyond the specific criteria set forth in this policy is considered not medically necessary. If the Drug Quantity Management rule is not met at the point of service, coverage will be determined by the policy criteria and may be denied unless the applicable criteria for an approved override are satisfied.

Product Dose and Limit Specifications

Maximum doses and example maximum quantities

Nurtec ODT (rimegepant) — per 24 hours75 mg (1 tablet) per 24 hours; safety of >18 doses in 30 days not established

Nurtec ODT — retail / home delivery examplesRetail max per 28 days: 16 tablets (2 boxes); Home delivery max per 84 days: 48 tablets (6 boxes)

Reyvow (lasmiditan) — per 24 hoursNo more than 1 dose should be taken in 24 hours; recommended doses 50 mg, 100 mg, or 200 mg

Reyvow — retail / home delivery examplesRetail max per 28 days: 8 tablets (1 box); Home delivery max per 84 days: 24 tablets (3 boxes)

Ubrelvy (ubrogepant) — per 24 hoursRecommended 50 mg or 100 mg; maximum dose 200 mg per 24 hours; safety of >8 migraines in 30 days not established

Ubrelvy — retail / home delivery examplesRetail max per 28 days: 20 tablets (2 boxes); Home delivery max per 84 days: 60 tablets (6 boxes)

Zavzpret (zavegepant) — per 24 hours and supply examplesRecommended dose 10 mg (one spray) per 24 hours; Retail max per 28 days: 12 units (2 cartons); Home delivery max per 84 days: 36 units (6 cartons)

Provider Actions and Approval Guidance

Prior Authorization

Quantity limit approvals and overrides

Approvals are provided for the duration noted in the Drug Quantity Limits when drug quantity limits are met. If limits are exceeded, coverage will be determined by the criteria-based review described in the policy. Quantity limits are specific to a chemical entity within the same dosage form; conventional tablets and orally disintegrating tablets are considered the same dosage form for these purposes.

Approvals follow the duration listed with each drug in the Drug Quantity Limits section.
Quantity limits are rounded up to the nearest whole package when needed.
If the Drug Quantity Management rule is not met at the point of service, a clinical review against the policy criteria will determine coverage.

Step Therapy

Clinical step: consider prevention for frequent use

Use of acute migraine medications on a regular basis can lead to medication‑overuse headache. Guidelines recommend limiting acute (abortive) therapy to less than 2 days per week or fewer than 8 treatment days per month. If a patient requires acute therapies more frequently, re-evaluate the diagnosis and assess the need for preventive (prophylactic) therapy.

Frequent use defined as >2 days/week or >8 days/month — consider preventive therapy.
Medication‑overuse headache generally defined as use on 10 or more days per month for 3 months or more.

Documentation Required

Required considerations for coverage

Coverage determinations require consideration of the applicable benefit plan terms, any applicable laws and regulations, relevant collateral source materials (including this coverage policy), and the specific facts of the individual case. In the event of a conflict, the member's benefit plan document supersedes this policy. Medical directors retain discretion to make individual coverage determinations.

Review the member's specific benefit plan document (Evidence of Coverage/Certificate/SPA) for coverage terms or exclusions.
Apply any applicable federal or state mandates.
Consider relevant clinical guidelines and the facts of the case when performing criteria‑based review.

Background

Nurtec ODT (rimegepant orally disintegrating tablet), Reyvow (lasmiditan), Ubrelvy (ubrogepant) and Zavzpret (zavegepant nasal spray) are indicated for the acute treatment of migraine in adults; Nurtec ODT also has an indication for prevention of episodic migraine. These products are acute migraine therapies and the policy’s Drug Quantity Management program is intended to prevent stockpiling, misuse, and overuse of such agents. Clinical guidance recognizes that frequent use of acute therapies can result in medication‑overuse headache, and the policy therefore defines per‑day and per‑period quantity limits (for example, Zavzpret retail maximum of 12 units per 28 days) and limited one‑time overrides only in specified circumstances.

Definitions

Medication‑overuse headache — definition and thresholds

DefinitionMedication‑overuse headache: a headache condition potentially caused by frequent use of acute migraine medications, generally defined as use for 10 or more days per month for 3 months or more.

Recommended limitLimit acute (abortive) therapy to less than 2 days per week or about 8 treatment days per month to reduce risk.

Clinical action if exceededIf patients require abortive therapies more frequently, re-evaluate the diagnosis and assess for preventive therapy.