CurrentCignaPolicy N/A

Migraine Medication Step Therapy Policy

Defines step therapy requirements for coverage of triptan and related migraine medications for Cigna-administered health benefit plans; affects prescribers and prior authorization reviewers.

Policy Summary

PayerCigna

PolicyMigraine Medication Step Therapy Policy

Policy CodePolicy N/A

Change TypeStep list revisionsproduct additions/removals

Effective DateN/A

Next Review DateN/A

Key ActionMust trial one Step 1 Product prior to coverage of a Step 2 Product.

SourceLink

POLICY UPDATE CHANGES

Generic almotriptan tablets removed from Step 1 and added to Step 2; generic frovatriptan tablets removed from Step 1 and added to Step 2.

Symbravo added to the policy as a Step 2 Product.

Zomig-ZMT (brand) removed from Step 2 as obsolete; Alsuma and Sumavel DosePro removed as obsolete.

Removed note regarding Zomig nasal spray DAW9 counting as a Step 1 Product due to removal from Standard DAW9 Program.

2Step levels

1 yearAuth duration

≥1Required trials

multipleFormulations listed

Coverage Criteria

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Initial Step Therapy

Covered when ALL of the following are met

Step requirement: Patient has tried one Step 1 Product1 trial

If met, a Step 2 Product may be approved for coverage for up to 1 year

Triptans — including combination agents such as Treximet (sumatriptan + naproxen) and Symbravo (rizatriptan + meloxicam) — are indicated for the acute treatment of migraine headache with or without aura in adults. They are not intended for prophylactic migraine therapy and are not indicated for management of hemiplegic or basilar migraine. Only sumatriptan injection is approved for cluster headache; safety and efficacy have not been established for oral triptans for cluster headache. Some triptans have pediatric/adolescent approvals (for example, almotriptan and rizatriptan), and certain formulations (e.g., orally disintegrating tablets) offer alternative routes of administration.

Any use of migraine medications that does not meet the Step Therapy requirements described in this policy or is not otherwise approved by the policy is considered not medically necessary. This policy’s Step Therapy program requires trial of a Step 1 Product prior to coverage of a Step 2 Product; exceptions must be supported by the criteria in the policy.

Step 1 and Step 2 Product Lists (Codes)

Step 1 Productsmixed

generic eletriptan tablets	Step 1 product
generic naratriptan tablets	Step 1 product
generic rizatriptan tablets	Step 1 product
generic rizatriptan orally disintegrating tablets	Step 1 product
generic sumatriptan tablets	Step 1 product
generic sumatriptan nasal spray	Step 1 product
generic sumatriptan injection	Step 1 product
generic zolmitriptan orally disintegrating tablets	Step 1 product
generic zolmitriptan tablets	Step 1 product

Step 2 Productsmixed

generic almotriptan tablets	Step 2 product
Amerge (naratriptan) tablets	Step 2 product
Frova (frovatriptan) tablets (brand and generic)	Step 2 product
Imitrex (sumatriptan) tablets	Step 2 product
Imitrex Nasal Spray	Step 2 product
Imitrex Injection	Step 2 product
Maxalt (rizatriptan) tablets	Step 2 product
Maxalt MLT (rizatriptan ODT)	Step 2 product
Migranal (dihydroergotamine nasal spray) (brand and generic)	Step 2 product
Onzetra Xsail (sumatriptan nasal powder)	Step 2 product

1–10 of 18

1/2

Provider Actions and Requirements

Step Therapy

Step therapy requirement — Step 1 required prior to Step 2 coverage

This program requires that providers ensure one Step 1 product is tried before a Step 2 product is approved. If the Step Therapy rule is not met at the point of service for a Step 2 product, coverage will be determined by the Step Therapy criteria below. All approvals are provided for 1 year in duration.

Step 1 products include: generic eletriptan tablets; generic naratriptan tablets; generic rizatriptan tablets; generic rizatriptan orally disintegrating tablets; generic sumatriptan tablets; generic sumatriptan nasal spray; generic sumatriptan injection; generic zolmitriptan orally disintegrating tablets; generic zolmitriptan tablets.
Step 2 products include: generic almotriptan tablets; Amerge tablets; Frova tablets (brand and generic); Imitrex tablets; Imitrex Nasal Spray; Imitrex Injection; Maxalt tablets; Maxalt MLT; Migranal (brand and generic); Onzetra Xsail; Relpax; Symbravo; Tosymra; Treximet tablets (brand and generic); Trudhesa; Zembrace Symtouch; Zomig tablets; Zomig nasal spray (brand and generic).

Prior Authorization

Provider action for step therapy — document trial of a Step 1 product

If the Step Therapy requirement is not met, coverage decisions for a Step 2 product will be made at the point of service according to the Step Therapy criteria. Providers should document prior use of a Step 1 product when seeking coverage for a Step 2 product; approvals are typically granted for one year.

Providers must trial at least one Step 1 product before prescribing a Step 2 product to meet the step therapy requirement.
If the required trial is not documented at point of service, prior authorization or clinical review may be required to determine medical necessity.

Denial Risk

Denial triggers — billing must match covered codes and indications

Claims submitted without covered diagnosis or procedure codes consistent with this policy will be denied. Reimbursement is not allowed for services billed for diagnoses or conditions that are not covered under this coverage policy.

Claims without covered diagnosis/procedure codes per the applicable coverage policy will be denied as not covered.
Denials may occur if the billing codes do not reflect an approved indication or if the service was not submitted in accordance with the applicable coverage criteria.

Documentation Required

Required documentation and billing

When requesting coverage or submitting claims, providers must include documentation supporting the trial of a Step 1 product and the clinical rationale for using a Step 2 product. Use the most appropriate and current diagnosis and procedure codes as of the date of service.

Include clinical notes documenting trial and response (or intolerance/contraindication) to ≥1 Step 1 product.
Attach prior authorization forms and any supporting clinical records when required.
Use appropriate CPT/HCPCS/ICD-10 codes that match the policy-supported indication; claims with unsupported codes will be denied.

Definitions

Treximet — definition and key facts

Generic nameSumatriptan + naproxen sodium

Branded productTreximet

IndicationAcute treatment of migraine headache with or without aura in adults

MechanismCombination of a triptan (serotonin 5-HT1B/1D agonist) and an NSAID (naproxen) providing dual mechanisms for acute migraine

Age approvals noted in policyTreximet approved for patients ≥ 12 years for acute migraine

Symbravo — definition and key facts

Generic componentsRizatriptan + meloxicam

Branded productSymbravo

IndicationAcute treatment of migraine headache with or without aura in adults

MechanismCombination of a triptan (rizatriptan) and an NSAID (meloxicam) offering two pharmacologic actions in one tablet

Policy placementListed among triptan medications subject to step therapy requirements

OpenPayer

Migraine Medication Step Therapy Policy

Coverage Criteria

Step 1 and Step 2 Product Lists (Codes)

Provider Actions and Requirements

Background

Definitions