CurrentCignaPolicy IP0377

Migraine - Qulipta

This Cigna coverage policy governs prior authorization and coverage criteria for Qulipta (atogepant) for migraine prevention in adults under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyMigraine - Qulipta

Policy CodePolicy IP0377

Change TypeMaterial updates to step therapy and prior requirement timing

Effective Date5/15/2025

Next Review Date

Key ActionObtain prior authorization and document age, baseline monthly migraine days (≥4), and preferred product criteria for Individual and Family Plans.

SourceLink

POLICY UPDATE CHANGES

Removed requirement that patients try Botox or at least two standard prophylactic pharmacologic therapies from different classes before Qulipta.

Added preferred product criteria for Individual and Family Plans.

Policy name updated from 'Atogepant' to 'Migraine - Qulipta.'

≥ 4required migraine headache days per month to qualify

≥ 18minimum patient age for approval (years)

1 yearapproval duration when criteria met

IP0377coverage policy identifier

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Coverage Criteria for Qulipta (atogepant)

FDA-Approved Indication: Migraine Headache Prevention (Initial/Continuation)

Approve for 1 year if the patient meets the following (A, B, C, and D):

A: Patient is >= 18 years of age

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

Updated language specifies timing 'prior to initiating a migraine-preventive medication'

C: If the patient is 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 severe migraine days/month

D: Preferred product criteria is met for the product as listed for Individual and Family Plans

For Individual and Family Plans, Qulipta requires failure, contraindication, or intolerance to Emgality

Concurrent use of Qulipta with another calcitonin gene-related peptide (CGRP) inhibitor when that other agent is being prescribed for migraine headache prevention is considered not medically necessary. The policy explicitly lists concurrent use with another CGRP inhibitor for migraine prevention as a non-covered use and notes the class agents (injectable and oral) that have not been studied in combination.

Use of Qulipta (atogepant) for any indication other than migraine prevention is considered not medically necessary. The policy states that Qulipta for other uses is not covered and that the non-medically necessary list may be updated as new published data become available.

Key Coding & Eligibility Metrics

inv-04: Monthly migraine headache days — numeric threshold for eligibility

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

PurposeThreshold used to determine eligibility for Qulipta (atogepant) for migraine prevention

Documentation requiredProvider must document baseline monthly migraine headache days in prior authorization request

inv-05: Minimum age — patient age requirement for approval

Minimum age≥ 18 years

Applies toAdults being considered for Qulipta (atogepant) for migraine prevention

Provider Requirements, Prior Authorization, and Billing

Prior Authorization

Prior Authorization Required

Prior authorization is required for Qulipta. Approvals are provided for the durations noted (approve for 1 year if criteria met).

Prior authorization required for Qulipta (approve for 1 year if criteria met).

Step Therapy

Individual and Family Plans Requirement

For Individual and Family Plans, coverage of Qulipta requires failure, contraindication, or intolerance to Emgality per the preferred product criteria.

Individual and Family Plans: Qulipta criteria = Failure, contraindication, or intolerance to Emgality.

Background on Qulipta and Migraine

Qulipta (atogepant) is an oral calcitonin gene-related peptide (CGRP) receptor antagonist indicated for the preventive treatment of migraine in adults. Migraine is characterized by recurrent headaches with associated features such as nausea and sensitivity to light and sound; the policy distinguishes chronic migraine (headache on ≥15 days/month with migraine features on ≥8 days/month) from episodic migraine (<15 days/month).

Clinical Definitions

inv-13: Chronic migraine — Headache occurring on ≥15 days/month for >3 months with features of migraine on ≥8 days/month.

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

SourceInternational Headache Society definition as cited in policy

Clinical relevanceDistinguishes chronic from episodic migraine for treatment considerations

inv-14: Episodic migraine — Headaches that occur on <15 days/month.

Definition (Episodic migraine)Headaches that occur on <15 days/month.

ContrastLess frequent than chronic migraine (<15 days/month)

Policy Revision History

2025-05-15Annual revision / effective dateLatest

Policy revised on 05/15/2025 (annual revision) with no clinical criteria changes noted for that entry; policy effective date recorded as 5/15/2025.

2024-07-15Material change - clinical criteria removed

Removed requirement that patients try Botox or at least two standard prophylactic pharmacologic therapies from different classes before Qulipta.

2024-07-15Material change - timing language updated

Policy Summary

PayerCigna

PolicyMigraine - Qulipta

Policy CodePolicy IP0377

Change TypeMaterial updates to step therapy and prior requirement timing

Effective Date5/15/2025

Next Review Date

Key ActionObtain prior authorization and document age, baseline monthly migraine days (≥4), and preferred product criteria for Individual and Family Plans.

SourceLink

On This Page

Documentation requiredProvider must document patient age in prior authorization request

Denial Risk

Concurrent CGRP Inhibitor Use Not Allowed

Concurrent use of Qulipta with another CGRP inhibitor prescribed for migraine prevention is considered not medically necessary and will be denied.

Concurrent CGRP inhibitor use (e.g., Aimovig, Ajovy, Emgality, Vyepti, Nurtec ODT) with Qulipta for migraine prevention is not allowed.

Documentation Required

Prior Authorization Documentation Required

Providers must document patient age, baseline migraine headache days per month (≥4), current benefit of Qulipta if continuing therapy, and that preferred product criteria are met. Additionally, receipt of sample product does not satisfy criteria requirements.

Document age (≥18) and baseline migraine days per month (≥4).
If continuing Qulipta, document significant clinical benefit as determined by the prescriber (examples: reduction in overall migraine days or severe migraine days).
Confirm preferred product criteria are met.
Receipt of sample product does not satisfy coverage criteria.

Billing Rule

Coding and Claims

Claims submitted without covered diagnosis/procedure codes under the applicable Coverage Policy will be denied as not covered. When billing, providers must use the most appropriate codes as of the date of service.

Claims lacking covered diagnosis/procedure codes per this Coverage Policy will be denied as not covered.
Use the most appropriate codes in effect on the date of service.

Clinical relevanceUsed to categorize migraine frequency when assessing preventive therapy need

Updated timing language from 'prior to initiating Qulipta' to 'prior to initiating a migraine‑preventive medication' for the requirement of ≥4 monthly migraine headache days.

2024-07-15Material change - preferred product added

Added preferred product criteria for Individual and Family Plans (failure, contraindication, or intolerance to Emgality required before Qulipta for those plans).