CurrentColorado Rocky Mountain Health PlansPolicy UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2025 P 2189-14

Prior Authorization/Medical Necessity - Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), Zavzpret (zavegepant)

Defines prior authorization and medical necessity criteria for Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant) and Zavzpret (zavegepant) for acute and preventive migraine treatment, including initial and reauthorization requirements, contraindications/intolerance/step therapy expectations, coverage duration, and program-specific notes and state exceptions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization/Medical Necessity - Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), Zavzpret (zavegepant)

Policy CodePolicy UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2025 P 2189-14

Change TypeRevised (annual/iterative updates)

Effective DateMay 1, 2025

Next Review Date

Key ActionObtain prior authorization and document required prior triptan and preventive therapy trials (names and dates); approvals issued for 12 months when criteria met.

POLICY UPDATE CHANGES

Effective 5/1/2025 program in place; multiple prior revisions recorded from 3/2020 through 2/2025 reflecting iterative updates to triptan requirements, CGRP steps, inclusion of Zavzpret, Qulipta criteria updates, and state-specific footnotes.

12 monthsAuthorization duration

>=3 episodesTriptan trial requirement (acute)

>=30 daysTriptan trial minimum duration

Preventive therapy trial duration

>=4 daysMigraine days threshold (preventive)

Coverage Summary

Defines prior authorization and medical necessity criteria for Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant) and Zavzpret (zavegepant) for acute and preventive migraine treatment. Policy requires trial of lower-cost options and existing preventive therapies prior to coverage and specifies triptan and preventive trial thresholds (e.g., triptan requirement: after at least 3 migraine episodes and a minimum 30-day trial; preventive trial duration: at least 2 months; migraine days threshold for preventive Nurtec/Qulipta: ≥4 days).

Status: CURRENT. Coverage stance: covered_with_criteria. Authorization duration when criteria met: 12 months.

Note: State mandates and member-specific benefit plans may modify criteria (e.g., Connecticut/Kentucky/Mississippi have modified trial duration; California has specific modifications to non-CGRP preventive trial requirements). Coverage may also be impacted by other utilization management programs and plan benefits.

Surface key thresholds / quick facts

Authorization duration12 months

Triptan trial requirement (acute)>= 3 migraine episodes AND minimum 30-day trial

Preventive therapy trial duration>= 2 months

Migraine days threshold for preventive Nurtec/Qulipta>= 4 migraine days per month

Program effective dateEffective 5/1/2025

Initial Therapy Criteria

Nurtec ODT - Initial Authorization

Approved when ONE of the following sets of criteria is met:

ANY of the following

Acute treatment pathway
- Used for acute treatment of migraine
- Triptan failure
  - Triptans (choose 2)
    almotriptan (Axert)
    eletriptan (Relpax)

Continuation / Reauthorization Criteria

Concomitant Use / Exclusions

The policy prohibits concomitant use of acute CGRP receptor antagonists: acute agents must not be used in combination with another acute CGRP antagonist (examples cited: Nurtec ODT, Ubrelvy, Zavzpret).

For preventive use, the policy prohibits combining CGRP antagonists/inhibitors for preventive treatment: preventive agents must not be used in combination with another preventive CGRP antagonist or inhibitor (examples cited: Aimovig, Ajovy, Emgality, Qulipta, Vyepti, Nurtec ODT where applicable).

Concomitant therapy prohibitions apply to both initial authorization and reauthorization pathways and are explicitly enforced as a condition for approval and continued coverage.

Applicable Codes

Drugs mentioned (no billing codes provided in document)mixed

	Nurtec ODT (rimegepant) - acute and preventive indications
	Qulipta (atogepant) - preventive indication
	Ubrelvy (ubrogepant) - acute indication
	Zavzpret (zavegepant) - acute indication
	Triptans: almotriptan (Axert), eletriptan (Relpax), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt/Maxalt MLT), sumatriptan (Imitrex), zolmitriptan (Zomig/Zomig-ZMT), sumatriptan nasal spray, Zomig nasal spray
	Preventive comparators: betablockers (atenolol, metoprolol, nadolol, propranolol, timolol), candesartan (Atacand), divalproex sodium (Depakote/Depakote ER), onabotulinumtoxinA (Botox), SNRIs (duloxetine, venlafaxine), topiramate (Topamax), tricyclics (amitriptyline, nortriptyline), other CGRP agents (Aimovig, Ajovy, Emgality, Vyepti)

Provider Actions / Requirements

Prior Authorization

Prior authorization required

Prior authorization is required for these agents. When criteria are met, authorization will be issued for 12 months.

Documentation Required

Document trials, dates, and contraindications

Document the specific triptan agents tried and the date(s) of trial (required triptan trials and minimum 30-day trial for acute pathways). Document trials, dates, and any contraindication or intolerance to required prophylactic therapies (preventive trials generally require at least a 2-month trial). For Zavzpret, document duration of triptan trials including at least one oral triptan and one nasal triptan trial when required, and attest if the patient is not a candidate for oral or sublingual CGRP agents (e.g., due to nausea/vomiting, gastroparesis, inability to swallow).

Clinical Evidence & Definitions

14P&T approval entries (3/2020–2/2025)

12 moAuthorization duration per approval

30d / 2moRequired trial durations: triptans 30 days; preventive trials 2 months

Pkg insertsKey references: Nurtec ODT Apr 2024; Qulipta Jun 2023; Ubrelvy Jun 2023; Zavzpret Mar 2023; AHS/ICHD guidance

CGRP receptor antagonists (rimegepant, atogepant, ubrogepant, zavegepant) are indicated for the acute and/or preventive treatment of migraine. The program requires members to try lower-cost options prior to coverage and bases preventive selection on efficacy, tolerability, patient preference, headache subtype and comorbidities. Evidence and guidance cited include product package inserts (Nurtec ODT Apr 2024, Qulipta Jun 2023, Ubrelvy Jun 2023, Zavzpret Mar 2023) and AHS/ICHD guidance.

References: Nurtec ODT [package insert] Apr 2024; Qulipta [package insert] Jun 2023; Ubrelvy [package insert] Jun 2023; Zavzpret [package insert] Mar 2023; American Headache Society and ICHD guidance referenced for clinical context and preventive selection.

Revision History

2025-05-01revisedLatest

2/2025revised

Added footnote for California specific requirement.

8/2024revised

Updated Zavzpret step and list of potential prophylactic therapies.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization/Medical Necessity - Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), Zavzpret (zavegepant)

Policy CodePolicy UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2025 P 2189-14

Change TypeRevised (annual/iterative updates)

Effective DateMay 1, 2025

Next Review Date

Key ActionObtain prior authorization and document required prior triptan and preventive therapy trials (names and dates); approvals issued for 12 months when criteria met.

On This Page

frovatriptan (Frova)

naratriptan (Amerge)

rizatriptan (Maxalt/Maxalt MLT)

sumatriptan (Imitrex)

zolmitriptan (Zomig/Zomig-ZMT)

Prophylactic therapy or frequency exceptions

A betablocker (atenolol, metoprolol, nadolol, propranolol, or timolol)
Candesartan (Atacand)
A CGRP antagonist or inhibitor for preventive treatment (e.g., Aimovig, Ajovy*, Emgality, Qulipta, Vyepti)
Divalproex sodium (Depakote/Depakote ER)
OnabotulinumtoxinA (Botox)
[coverage may be subject to additional review]
A serotonin-norepinephrine reuptake inhibitor (duloxetine, venlafaxine)
Topiramate (Topamax)
A tricyclic antidepressant (amitriptyline, nortriptyline)
OR: Patient has < 4 migraine days per month
OR: Patient has >= 4 migraine days per month and has contraindication or intolerance to one of the prophylactic therapies listed above (documented)

Concomitant therapy prohibition: Medication will not be used in combination with another acute CGRP antagonist (e.g., Ubrelvy, Zavzpret)

Preventive episodic migraine pathway

Diagnosis of episodic migraines with >= 4 migraine days per month
Used for preventive treatment of migraines
History of failure (after a trial of at least two months), contraindication or intolerance to two of the following prophylactic therapies (document name and date tried): betablockers, candesartan, divalproex
Concomitant preventive CGRP prohibition: Medication will not be used in combination with another CGRP antagonist or inhibitor used for preventive treatment (e.g., Aimovig, Ajovy*, Emgality, Qulipta, Vyepti)

Alternative preventive/other clauses: Alternative clauses: patient has >=4 migraine days/month with contraindication/intolerance to one prophylactic therapy OR alternative listed therapies apply; medication will not be used with another preventive CGRP

Billing Rule

Concomitant therapy prohibition

Medications must not be used in combination with other CGRP antagonists in the same treatment setting: acute agents must not be combined with another acute CGRP antagonist (examples: Ubrelvy, Zavzpret, Nurtec acute use), and preventive use must not be combined with another preventive CGRP antagonist/inhibitor (examples: Nurtec preventive, Qulipta, Aimovig, Ajovy, Emgality, Vyepti).

Acute: do not combine with other acute CGRP antagonists (e.g., Ubrelvy, Zavzpret, Nurtec acute).
Preventive: do not combine with other preventive CGRP antagonists/inhibitors (e.g., Nurtec preventive, Qulipta, Aimovig, Ajovy, Emgality, Vyepti).

Step Therapy

Step requirements

Coverage requires trying lower-cost or specified trialist therapies before these agents: for acute use, documented failure/intolerance of specified triptans after at least 3 migraine episodes and a minimum 30-day trial (Zavzpret additionally requires a nasal triptan trial and provider attestation if oral/sublingual CGRPs are not an option). For preventive indications, documented failure of required prophylactic therapies after recommended trial durations (generally at least 2 months). State mandates and member benefit plan rules may modify these step requirements (e.g., some states have altered trial durations or removed non-CGRP preventive requirements).

Documentation Required

Positive clinical response for reauthorization

Reauthorization requires documentation of a positive clinical response to therapy; reauthorizations are issued for 12 months. For acute agents, the documentation must also confirm the agent is not being used in combination with another acute CGRP antagonist; for preventive agents, documentation must confirm no combination with another preventive CGRP antagonist/inhibitor.

Definitions (policy)

CGRP (definition)Calcitonin gene-related peptide receptor

Positive clinical responseDocumented clinical improvement as determined by provider (no numeric threshold specified)

Triptan trial duration (Trial)Documented use for minimum duration of 30 days for triptan trials

Preventive trial duration (Trial)Documented use for minimum duration of 2 months for preventive trials

6/2024revised

Removed notation that Qulipta is typically excluded from coverage; removed CGRP step for Qulipta; updated regulatory requirement and references.

12/2023revised

Removed CGRP step, added a provider attestation and updated the triptan step for Zavzpret; removed that Zavzpret is typically excluded from coverage; updated references.

7/2023revised

Added Zavzpret; updated Qulipta criteria to allow both episodic and chronic migraines; updated examples in prophylactic coverage and included Botox as preventive option for Qulipta.

3/2023revised

Annual review; added Zomig-ZMT as zolmitriptan example; added Qulipta as a prophylactic CGRP example and removed reference to biologic; updated references.

5/2022revised

Removed the step through the injectable CGRPs for Nurtec ODT; added a step through Nurtec ODT for Qulipta; updated products typically excluded from coverage and added note for Vyepti; updated references.

3/2022revised

Changes recorded (details in change log).

12/2021revised

Added Qulipta for preventive treatment of migraines and added candesartan as a preventive option; updated references.

7/2021revised

Added criteria for new preventive indication for Nurtec ODT; updated trial language to include 3 migraine episodes and added statement regarding concomitant therapy with other preventive CGRPs.

2/2021revised

Removed moderate to severe migraine requirement; added requirement for < 4 migraines per month; simplified criteria for >= 4 migraines per month; added biologic CGRP to prophylactic therapies; removed prescriber requirement from reauthorization.

9/2020revised

Added a step requirement for Nurtec ODT through Ubrelvy and noted Nurtec ODT is typically excluded from coverage; modified concomitant CGRP language.

7/2020revised

Updated requirement from three triptans to two triptans and modified concomitant CGRP language.

3/2020revised

New program established (initial program creation).