CurrentCignaPolicy IP0377

Migraine - Qulipta (atogepant) coverage criteria

Defines Cigna's prior authorization and medical necessity criteria for coverage of Qulipta (atogepant) for preventive treatment of migraine in adults under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyMigraine - Qulipta (atogepant) coverage criteria

Policy CodePolicy IP0377

Change TypeMaterial criteria updates (step-therapy relaxationwording clarifications)

Effective DateApr 15, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests with appropriate diagnosis/procedure codes; approvals are issued for 1 year when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Removed prior requirements that patients must have tried Botox or at least two standard prophylactic pharmacologic therapies from different classes before initiating Qulipta.

Updated requirement wording from 'prior to initiating Qulipta' to 'prior to initiating a migraine-preventive medication' regarding the 4 or more monthly migraine headache days threshold.

Added preferred product criteria for Individual and Family Plans (later removed in a subsequent revision).

≥4migraine days threshold

≥18minimum age

1 yearapproval duration

Concurrent CGRP agentsnot covered

Policy Summary

PayerCigna

PolicyMigraine - Qulipta (atogepant) coverage criteria

Policy CodePolicy IP0377

Change TypeMaterial criteria updates (step-therapy relaxationwording clarifications)

Effective DateApr 15, 2026

Next Review DateN/A

Key ActionSubmit prior authorization requests with appropriate diagnosis/procedure codes; approvals are issued for 1 year when criteria are met.

SourceLink

On This Page

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Coverage and Medical Necessity Criteria

Medically Necessary Criteria

Qulipta is considered medically necessary when meeting the FDA-approved indication criteria for migraine prevention in adults.

FDA-Approved Indication: Approve for the duration noted if the patient meets ONE of the following (A or B)

A) Initial Therapy: Approve for 1 year if the patient meets BOTH of the following

A.i: Patient is ≥ 18 years of age

A.ii: Patient has ≥ 4 migraine headache days per month (prior to initiating a migraine-preventive medication)>=4 monthly migraine days

B) Patient Currently Receiving Qulipta: Approve for 1 year if the patient meets ALL of the following

B.i: Patient is ≥ 18 years of age

B.ii: Patient has ≥ 4 migraine headache days per month (prior to initiating a migraine-preventive medication)>=4 monthly migraine days

B.iii: If currently taking Qulipta, patient has had a significant clinical benefit from the medication as determined by the prescriber (examples include reduction in overall number of migraine days/month or reduction in number of severe migraine days/month)

Use of Qulipta (atogepant) for any indication other than migraine headache prevention is considered not medically necessary. The policy explicitly excludes concurrent use of Qulipta with another calcitonin gene-related peptide (CGRP) inhibitor when that agent is being prescribed for migraine prevention.

Concurrent use of Qulipta with another CGRP inhibitor prescribed for migraine prevention (for example, Aimovig, Ajovy, Emgality, Vyepti, or Nurtec ODT) is explicitly not covered and will be considered not medically necessary. Note that several CGRP-targeting products are injectable and have not been studied in combination with another agent in the same class; providers should avoid prescribing overlapping CGRP preventive therapies.

Coding and Claim Expectations

Coding expectations (no explicit code list)mixed

affected codes

Policy references that providers must use appropriate diagnosis and procedure codes as of the effective date; specific CPT/HCPCS/NDC codes not enumerated in document.

Monthly migraine headache days — key threshold value used in approval decisions

Monthly migraine headache days threshold≥ 4 migraine headache days per month (prior to initiating a migraine‑preventive medication)

Context of useRequired for both Initial Therapy and patients currently receiving Qulipta (listed in FDA‑Approved Indication criteria)

Approval duration when threshold met1 year (approval provided when criteria, including the monthly migraine days threshold, are met)

Prior Authorization, Documentation, and Provider Steps

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage of Qulipta. All approvals are provided for a duration of 1 year. Submit PA requests with documentation supporting the indication, patient age, baseline migraine days per month, and clinical benefit for renewals.

Approval duration: 1 year
Required documentation: patient age, baseline migraine headache days/month (≥ 4), prior preventive medication history when applicable, and for continuation requests — documentation of significant clinical benefit as determined by the prescriber (e.g., reduction in monthly migraine days or severe migraine days).
Submit supporting clinical records and prior authorization forms to the payer's PA portal or designated fax per plan instructions.

Step Therapy

Step Therapy Waivers / First-Line Positioning

Step-therapy requirements for Qulipta have been removed: Qulipta and other CGRP-targeting therapies are positioned as first-line options for migraine prevention and do not require prior trial of Botox or two prophylactic therapy classes. Providers may request Qulipta without documenting failure of Botox or two distinct prophylactic drug classes.

Key Definitions

Chronic migraine — definition

Definition (ICHD) for chronic migraineHeadache occurring on ≥ 15 days/month for more than 3 months with migraine features on ≥ 8 days/month.

Minimum durationMore than 3 months of headache on ≥ 15 days/month

Migraine features requirementFeatures of migraine present on ≥ 8 days per month

Qulipta — atogepant definition and brief description

Generic nameAtogepant

Brand name and indicationQulipta — an oral calcitonin gene‑related peptide (CGRP) receptor antagonist indicated for the preventive treatment of migraine in adults.

Population

Clinical Background

Migraine is a recurring headache disorder that may present as episodic or chronic disease. Chronic migraine is characterized by headache on ≥ 15 days per month for more than 3 months with migraine features on ≥ 8 days per month. Qulipta (atogepant) is an oral calcitonin gene-related peptide (CGRP) receptor antagonist indicated for the preventive treatment of migraine in adults.