Migraine - Nurtec ODT
This Cigna coverage policy governs prior authorization and medical necessity criteria for Nurtec ODT (rimegepant) for acute treatment of migraine and preventive treatment of episodic migraine for insured members under Cigna-administered plans.
Updated coverage policy title from Rimegepant to Migraine - Nurtec ODT.
Migraine, Acute Treatment: Added requirement for trial of two triptans for Individual and Family Plans.
Preventive Treatment of Episodic Migraine: Removed requirement for a minimum 8-week trial as it relates to migraine prevention therapies.
Preventive Treatment: Added preferred product criterion for Individual and Family Plans requiring failure, contraindication, or intolerance to Emgality.
Coverage Criteria for Nurtec ODT (rimegepant)
Covered Indications and Criteria
Nurtec ODT is considered medically necessary when ONE of the following is met:
Acute Treatment (Approve 1 year)
Triptan trial or exception
- Trial requirement: Patient has tried one triptan product (e.g., almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan) OR has tried one triptan/NSAID combination product (e.g., Treximet or Symbravo) OR has taken a triptan concomitantly with an NSAID
- Contraindication or intolerance to triptans: Per the prescriber, the patient has a contraindication to triptans (examples include coronary artery disease, cardiac accessory conduction pathway disorders, history of stroke/transient ischemic attack, hemiplegic or basilar migraine, peripheral vascular disease, ischemic bowel disease, uncontrolled hypertension, or severe hepatic impairment) OR the patient has had a significant intolerance to one or more triptans
Examples of significant clinical benefit include reduction in overall migraine days/month or reduction in severe migraine days/month.
Concurrent use of Nurtec ODT with another calcitonin gene-related peptide (CGRP) inhibitor for migraine prevention is not permitted when Nurtec ODT is being used for the preventive treatment of episodic migraine. The policy explicitly lists concurrent CGRP inhibitor use as an exclusion for preventive therapy; clinical trials of Nurtec ODT for prevention did not allow concomitant medications acting on the CGRP pathway and other preventive CGRP agents have not been studied in combination with a same-class agent.
Nurtec ODT (rimegepant) is considered not medically necessary for any use outside the specified acute treatment or preventive episodic migraine indications. This includes, but is not limited to, concurrent use with another CGRP inhibitor for migraine prevention, which the policy identifies as a not medically necessary use and may be denied.
Coding and Eligibility Thresholds
| NDC/HCPCS/CPT not specified | No procedure, diagnosis, or billing codes are listed explicitly in the policy text. |
Provider Actions, Prior Authorization, and Documentation
Prior authorization required — obtain PA for coverage (1 year approvals)
Prior authorization is required for prescription benefit coverage of Nurtec ODT. All approvals are provided for the duration noted in the criteria (approve for 1 year when criteria are met). Operationally, submit a PA request and ensure the patient meets the plan-specific criteria for acute or preventive use to receive a 1‑year approval.
- All approvals are provided for the duration noted (typically 1 year).
- PA must be obtained before coverage; criteria for acute vs preventive use must be met.
Triptan trial required for acute treatment — follow plan-specific rules
For acute treatment, prescribers must document a trial of a triptan (or a triptan/NSAID combination) per plan rules before Nurtec ODT is approved; Employer and Individual/Family Plans have plan-specific preferred product/triptan trial requirements and exceptions for contraindication or intolerance.
- Employer Plans: trial of one triptan product OR one triptan/NSAID combination product (or concomitant triptan+NSAID), unless contraindicated or intolerant.
- Individual and Family Plans: triptan prerequisite steps were decreased to one; see preferred product tables for current plan-specific rules and added exceptions for triptan+NSAID combinations.
- Document prescriber-determined contraindication or significant intolerance if applicable.
Required clinical documentation — age, indication, baseline frequency, and benefit
Include the patient’s age and the treatment indication (acute vs preventive); for preventive requests, document baseline migraine frequency (≥4 and <15 migraine days/month). If requesting continuation, document that the patient has experienced significant clinical benefit as determined by the prescriber.
- Age: patient is ≥ 18 years.
- Indication: acute treatment or preventive treatment of episodic migraine.
- Preventive baseline: ≥ 4 and < 15 migraine headache days per month (prior to initiating preventive medication).
- Continuation: prescriber documentation of significant clinical benefit (e.g., reduction in overall migraine days/month or severe migraine days/month).
Denial risk — no PA or non‑covered/ concurrent CGRP prevention use
Claims submitted without prior authorization will be denied; requests for Nurtec ODT for uses other than the specified acute or preventive episodic migraine indications (including concurrent use with another CGRP inhibitor for prevention) are considered not medically necessary and may be denied.
- Nurtec ODT concurrent use with another CGRP inhibitor for migraine prevention is not allowed and is considered not medically necessary.
- Verify PA is approved before billing to avoid claim denials for lack of authorization or non-covered indications.
Background on Nurtec ODT
Nurtec ODT (rimegepant) is a small-molecule CGRP receptor antagonist indicated for the acute treatment of migraine with or without aura and for the preventive treatment of episodic migraine in adults. Examples of other CGRP-targeted therapies for prevention include injectable agents (e.g., Aimovig, Ajovy, Emgality, Vyepti) and oral agents (e.g., Qulipta); clinical trials of Nurtec ODT for prevention did not permit concomitant CGRP-pathway medications.
Definitions
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.