Migraine - Nurtec ODT
Defines Cigna prior authorization and medical necessity criteria for Nurtec ODT for acute treatment of migraine and for preventive treatment of episodic migraine in adults.
Decreased the number of triptan prerequisite steps for Individual and Family Plans from two to one for acute migraine treatment.
Removed requirement for a minimum 8-week trial related to migraine prevention therapies.
Added preferred product criterion for Individual and Family Plans requiring failure, contraindication, or intolerance to Emgality for acute treatment.
Preventive treatment criteria were reformatted into separate sets for Initial Therapy and Continuation of Therapy.
Coverage Criteria for Nurtec ODT (rimegepant)
inv-01: Migraine, Acute Treatment
Covered for Acute Treatment of Migraine when ALL of the following are met:
Acute Treatment - General
- Step Therapy Options: Either: trial of one triptan OR trial of one triptan/NSAID combination OR prescriber-documented contraindication to triptans OR prescriber-documented significant intolerance to triptansas documented
Employer and Individual/Family Plans require trial or documented exception; examples of contraindications include history of coronary artery disease, cardiac conduction disorders, stroke/TIA, hemiplegic or basilar migraine, peripheral vascular disease, ischemic bowel disease, uncontrolled hypertension, or severe hepatic impairment.
inv-02: Preventive Treatment of Episodic Migraine
Covered for Preventive Treatment of Episodic Migraine when the following criteria are met:
Preventive Treatment - Initial or Continuation
- Initial Therapy: Patient is ≥ 18 years of age AND has ≥ 4 and < 15 migraine headache days per month (prior to initiating a migraine-preventive medication)age >=18; 4<=days<15
Approve for 1 year
- Continuation of Therapy: Patient is ≥ 18 years of age AND has ≥ 4 and < 15 migraine headache days per month (prior to initiating a migraine-preventive medication) AND patient has had a significant clinical benefit from the medication as determined by the prescriberage >=18; 4<=days<15; documented benefit
Approve for 1 year; examples of significant clinical benefit include reduction in overall migraine days per month or reduction in number of severe migraine days per month
inv-03: Not Medically Necessary Uses
This list may not be all inclusive
When Nurtec ODT (rimegepant) is being used for preventive treatment of episodic migraine, concurrent administration with another calcitonin gene-related peptide (CGRP) pathway inhibitor is considered not medically necessary. Clinical trials of Nurtec ODT for prevention did not allow concomitant CGRP-targeting therapies, and other CGRP inhibitors indicated for prevention (for example, Aimovig, Ajovy, Emgality, Vyepti, and Qulipta) have not been studied in combination with another agent in the same class; therefore combined use for migraine prevention is not supported by the evidence and is excluded under this policy.
Providers prescribing Nurtec ODT for prevention should ensure that the patient is not receiving another CGRP-targeting preventive therapy. If records show concurrent use with a different CGRP inhibitor for migraine prevention, the request will be considered not medically necessary per policy and may be denied.
Nurtec ODT is covered only for its FDA‑approved indications: acute treatment of migraine and preventive treatment of episodic migraine in adults. Use of Nurtec ODT for any indication outside of these FDA‑approved uses is considered not medically necessary and is not covered under this policy.
Coding and Related Criteria
| Nurtec ODT | rimegepant orally disintegrating tablets (product name listed) |
| Aimovig | erenumab-aooe subcutaneous injection |
| Ajovy | fremanezumab-vfrm subcutaneous injection |
| Emgality | galcanezumab-gnlm subcutaneous injection |
| Vyepti | eptinezumab-jjmr intravenous infusion |
| Qulipta | atogepant tablets |
Provider Actions and Authorization Requirements
Prior authorization required; approvals typically 1 year
Prior authorization is required for benefit coverage of Nurtec ODT; approvals are provided for the durations noted in the policy (commonly 1 year).
- Approvals for both acute treatment and preventive treatment continuation/initial therapy are typically provided for 1 year.
Triptan step therapy — trial of one triptan or triptan+NSAID required (or documented exception)
For acute migraine, plans require a trial of at least one triptan product or one triptan/NSAID combination (or documentation of contraindication or significant intolerance) prior to Nurtec ODT; Individual and Family Plans were revised to reduce triptan prerequisite steps to one.
- Acceptable trials include one triptan (examples listed in policy) or one triptan/non‑steroidal anti‑inflammatory drug combination product (e.g., Treximet or Symbravo) or concomitant triptan + NSAID.
- A prescriber-documented contraindication to triptans or significant intolerance to one or more triptans satisfies the requirement.
Required prescriber documentation (age, migraine days, triptan trial/exception, benefit for continuation)
Prescribers must document patient age, migraine frequency for preventive indications, prior triptan use or documented contraindication/intolerance for acute treatment, and for continuation of preventive therapy document significant clinical benefit.
- Age: patient is ≥ 18 years for both acute and preventive indications.
- Preventive: document ≥4 and <15 migraine headache days per month prior to initiating preventive medication.
- Acute: document trial of one triptan or one triptan/NSAID combination, or prescriber-documented contraindication or significant intolerance to triptans.
- Continuation of preventive therapy: document significant clinical benefit as determined by the prescriber (e.g., reduction in migraine days or severe migraine days).
Coding/claims denial risk for missing or non‑covered codes
Claims not submitted with covered diagnosis or procedure codes under this Coverage Policy will be denied as not covered.
- When billing, providers must use the most appropriate covered codes as of the date of submission; services billed for conditions or diagnoses not covered under the policy will be denied.
- Lack of accompanying covered code(s) for the requested service is a basis for denial.
Background
Migraine is a common, episodic or chronic headache disorder characterized by paroxysmal, often unilateral moderate-to-severe throbbing head pain with associated symptoms such as nausea, photophobia, and phonophobia. Nurtec ODT (rimegepant) is a small‑molecule CGRP receptor antagonist indicated for both the acute treatment of migraine and for the preventive treatment of episodic migraine in adults. Clinical trials supporting preventive use did not permit concomitant CGRP‑targeting medications, and several CGRP‑directed therapies (including injectable monoclonal antibodies and other oral gepants) are available for migraine prevention; these agents have not been studied in combination with each other, which informs the policy restrictions on combined use.
Definitions
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