CurrentCignaPOLICY: Migraine - Ubrelvy Prior Authorization Policy

Migraine - Ubrelvy Prior Authorization Policy

Defines prior authorization criteria for coverage of Ubrelvy (ubrogepant) for acute treatment of migraine in adults under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyMigraine - Ubrelvy Prior Authorization Policy

Policy CodePolicy POLICY: Migraine - Ubrelvy Prior Authorization Policy

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document that the patient is ≥18 years and has tried at least one triptan or has a contraindication to triptans to approve Ubrelvy for 1 year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearapproval duration

≥18min age

1triptan trial

NMNother uses

Coverage Criteria for Ubrelvy (ubrogepant)

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FDA-Approved Indication — Acute Migraine

ONE of
- i) Triptan trial: Patient has tried at least one triptan therapy.
- ii) Triptan contraindication: According to the prescriber, the patient has a contraindication to triptan(s).
  Examples: history of coronary artery disease; cardiac accessory conduction pathway disorders; history of stroke, transient ischemic attack, or hemiplegic or basilar migraine; peripheral vascular disease; ischemic bowel disease; uncontrolled hypertension; or severe hepatic impairment.

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Prior authorization is recommended for prescription benefit coverage of Ubrelvy. All approvals are provided for the duration noted in the policy (approvals for acute migraine are typically for 1 year when criteria are met).

Drug: Ubrelvy (ubrogepant tablets)
Approval duration: 1 year when FDA‑approved acute migraine criteria met

Step Therapy

Step Therapy (Triptan Trial)

Step therapy: a trial of at least one triptan is required for approval of Ubrelvy for acute migraine unless the prescriber documents a contraindication to triptan therapy.

Required trial: ≥1 triptan (e.g., sumatriptan, rizatriptan, zolmitriptan, etc.)
Acceptable alternative: documented contraindication to triptan(s) (examples listed in policy)

Documentation Required

Benefit Plan and Coding Adherence

Benefit plan and coding adherence: Providers must submit prior authorization requests consistent with the member's applicable benefit plan. Requests should include sufficient clinical information to support the medical necessity criteria and the most appropriate diagnosis and procedure codes as of the date of submission. Claims billed with codes that are not covered under the applicable benefit plan will be denied.

Ensure request aligns with the member's benefit plan language and any applicable exclusions
Use most appropriate ICD-10/CPT/NDC codes on submissions
Provide supporting clinical documentation to demonstrate criteria (age, triptan trial or contraindication, diagnosis of acute migraine)

Denial Risk

Non‑covered Indications

Non‑covered indications: Ubrelvy is considered not medically necessary for any uses other than the FDA‑approved acute treatment of migraine (and other uses only if supportive evidence and criteria in the policy are met). Requests for uses outside those criteria will be denied.

Not covered: indications other than acute migraine unless policy criteria for other supported uses are explicitly met

Definitions

Chronic migraine definition — headache frequency criteria

Migraine-featured daysAt least 8 days per month must have migraine features (e.g., unilateral, throbbing, aggravated by routine activity, with nausea/photophobia/phonophobia).

Source definition authorityInternational Headache Society criteria as cited in the policy document.

Episodic migraine definition — headaches < 15 days/month

DefinitionEpisodic migraine: headaches that occur < 15 days/month.

Frequency thresholdFewer than 15 headache days per month distinguishes episodic from chronic migraine.

Clinical contextEpisodic migraine episodes may still include typical migraine features (unilateral, throbbing, associated symptoms).