CurrentCignaPolicy N/A

Migraine - Nurtec ODT Prior Authorization Policy

Defines Cigna's prior authorization requirements and coverage criteria for Nurtec ODT for acute migraine treatment and preventive treatment of episodic migraine for affected members and prescribers.

Policy Summary

PayerCigna

PolicyMigraine - Nurtec ODT Prior Authorization Policy

Policy CodePolicy N/A

Change TypeStep therapy removal (preventive)

Effective DateN/A

Next Review DateFeb 26, 2025

Key ActionSubmit prior authorization with documentation of age, indication, and required trials or contraindications; approvals issued for 1 year when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Preventive treatment criteria no longer require prior failure of two standard prophylactic pharmacologic therapies from different classes.

2FDA-approved indications covered

≥18 yrsMinimum age

4–<15Preventive migraine days

1 yrTypical approval duration

Concurrent CGRPNot covered

Coverage Criteria for Nurtec ODT (rimegepant)

Concurrent use of Nurtec ODT with another calcitonin gene-related peptide (CGRP) inhibitor when Nurtec ODT is being used for the preventive treatment of episodic migraine is considered experimental, investigational, or unproven and is not covered. Examples of CGRP inhibitors noted in the policy include Aimovig (erenumab), Ajovy (fremanezumab), Emgality (galcanezumab), Vyepti (eptinezumab), Nurtec ODT (rimegepant), and Qulipta (atogepant); injectable agents and Qulipta have not been studied in combination with another agent in the same class, and the preventive trials of Nurtec ODT did not allow concomitant CGRP-pathway medications.

Use of Nurtec ODT for any indication that is not an FDA-approved indication or otherwise supported by evidence in this policy is considered experimental, investigational, or unproven and therefore not covered.

Coding and Utilization Details

Neutral — codes not specifiedmixed

NDC/HCPCS/CPT not specified

The policy references Nurtec ODT prescribing information but does not list specific billing codes.

Migraine headache days per month for preventive indication — >=4 and <15

Preventive migraine-days threshold>=4 and <15 migraine headache days per month (prior to initiating a migraine‑preventive medication)

Policy Summary

PayerCigna

PolicyMigraine - Nurtec ODT Prior Authorization Policy

Policy CodePolicy N/A

Change TypeStep therapy removal (preventive)

Effective DateN/A

Next Review DateFeb 26, 2025

Key ActionSubmit prior authorization with documentation of age, indication, and required trials or contraindications; approvals issued for 1 year when criteria are met.

SourceLink

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Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Nurtec ODT. Approvals are provided for 1 year when criteria for the respective FDA‑approved indication are met.

A prior authorization (PA) request must indicate the intended FDA‑approved indication (acute treatment of migraine or preventive treatment of episodic migraine).
Approvals are issued for 12 months when all applicable criteria are satisfied.

Documentation Required

Required Documentation

Document the following in the medical record and include with the prior authorization request when applicable: patient age, specific indication being treated, history of prior therapies or contraindications, and clinician assessment of clinical benefit for continuation.

Patient age (must be ≥ 18 years for both acute and preventive indications).
For acute migraine: documentation that the patient has tried ≥ 1 triptan (name, dose, dates) or documentation of a prescriber‑stated contraindication to triptans (and the reason for the contraindication).
For preventive episodic migraine: documentation of baseline migraine days per month (must be ≥ 4 and < 15 prior to initiating preventive therapy).
For continuation of Nurtec ODT for prevention: documentation of significant clinical benefit while on Nurtec ODT (examples: reduction in monthly migraine days or reduction in severe migraine days as assessed by the prescriber).
Clinical notes, medication history, and any supporting diagnostic or assessment tools (e.g., headache diary, MIDAS, HIT‑6) when available.

Denial Risk

Triggers for Denial

Requests should be denied when required criteria or documentation are not met.

Patient does not meet age requirement (< 18 years).
For acute treatment: no evidence of trial of at least one triptan and no documented contraindication to triptans.
For preventive treatment: baseline migraine days per month do not meet threshold (fewer than 4 or ≥ 15).
Lack of documentation of clinical benefit for continuation requests for preventive use.
Concurrent use of Nurtec ODT with another CGRP‑targeting agent prescribed for migraine prevention (concomitant CGRP inhibitors for prevention are considered experimental/unproven).
Missing or incomplete medical record documentation to support the requested indication (e.g., absent medication history, absence of baseline headache frequency).

Clinical Definitions

Chronic migraine definition — ≥15 days/month for >3 months with migraine features on ≥8 days/month

Definition (ICHD)Headache occurring on ≥15 days/month for >3 months with migraine features on ≥8 days/month.

Timeframe requirementFrequency must be sustained for more than 3 months.

Migraine features requiredAt least 8 of the ≥15 monthly headache days must have migraine features.

Episodic migraine definition — headaches that occur <15 days per month

DefinitionHeadaches that occur <15 days per month (episodic migraine).

Contrast with chronic migraineEpisodic migraine is distinguished from chronic migraine, which is ≥15 days/month with migraine features on ≥8 days/month.

Relevance to coveragePolicy uses episodic vs. chronic classification to determine eligibility for preventive treatment (episodic defined as <15 days/month).

OpenPayer

Migraine - Nurtec ODT Prior Authorization Policy

Coverage Criteria for Nurtec ODT (rimegepant)

Coding and Utilization Details

Provider Actions, Prior Authorization, and Documentation

Clinical Definitions

Background