CurrentColorado Rocky Mountain Health PlansPolicy N/A

Step therapy for CGRP small-molecule migraine therapies

Defines step therapy prior authorization requirements for Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), and Zavzpret (zavegepant) for acute and preventive migraine treatment for members covered by the payer.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyStep therapy for CGRP small-molecule migraine therapies

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document required prior therapy (drug names, dates, and duration) showing specified trial failures before approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4medications covered by this program

12 moauthorization duration

2prior prophylactic therapy failures

1prior triptan failures for Zavzpret

30 daysmin trial for triptan failures

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Coverage Criteria for CGRP Small-Molecule Therapies

Acute treatment - Nurtec ODT or Ubrelvy

Approved when ALL of the following are met

Acute Nurtec/Ubrelvy approval: History of therapeutic failure (after at least 3 migraine episodes and a minimum of a 30-day trial), contraindication, or intolerance to two of the listed triptans; document name and date tried.2 triptan agents failed

Listed agents: almotriptan (Axert); eletriptan (Relpax); frovatriptan (Frova); naratriptan (Amerge); rizatriptan (Maxalt/Maxalt MLT); sumatriptan (Imitrex); zolmitriptan (Zomig/Zomig-ZMT)

Acute treatment - Zavzpret

Approved when ALL of the following are met

Zavzpret approval step 1: History of failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to one of the listed oral triptans; document duration of trial.1 oral triptan failed

Listed agents: almotriptan (Axert®); eletriptan (Relpax®); frovatriptan (Frova®); naratriptan (Amerge®); rizatriptan (Maxalt®/Maxalt-MLT®); sumatriptan (Imitrex®); zolmitriptan (Zomig®)

Zavzpret approval step 2: History of failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to one of the listed nasal spray triptans; document drug and date tried.1 nasal triptan failed

Listed agents: sumatriptan (Imitrex) nasal spray; zolmitriptan (Zomig) nasal spray; Both criteria required for approval

Prevention - Nurtec ODT (episodic)

Approved when ALL of the following are met

Nurtec prevention approval: History of failure (after a trial of at least two months), contraindication, or intolerance to two of the listed prophylactic therapies; document name and date tried.2 prophylactic therapies failed

Listed options include one of the following betablockers (atenolol, metoprolol, nadolol, propranolol, timolol); candesartan (Atacand); divalproex sodium (Depakote/Depakote ER); an SNRI (duloxetine, venlafaxine); topiramate (Topamax); a tricyclic antidepressant (amitriptyline, nortriptyline)

Prevention - Qulipta

Approved when ALL of the following are met

Qulipta prevention approval: History of failure (after a trial of at least two months), contraindication, or intolerance to two of the listed prophylactic therapies; document name and date tried.2 prophylactic therapies failed

Listed options include one of the following betablockers (atenolol, metoprolol, nadolol, propranolol, timolol); candesartan (Atacand); divalproex sodium (Depakote/Depakote ER); onabotulinumtoxinA (Botox) [coverage may be subject to additional review]; an SNRI (duloxetine, venlafaxine); topiramate (Topamax); a tricyclic antidepressant (amitriptyline, nortriptyline)

Other diagnoses

Approved when diagnosis supports use

Other diagnoses: Ubrelvy, Nurtec ODT, Qulipta or Zavzpret will be approved for other diagnoses when the diagnosis supports use and diagnostic justification is documented.N/A

Authorization will be issued for 12 months

Certain state-specific exceptions apply to the preventive therapy requirements. For members in Connecticut, Kentucky, and Mississippi, only a 30‑day trial of preventive therapy is required. For California business, a trial of non‑CGRP preventive treatments is not required. Note that prior authorization will be issued for 12 months when criteria are met, and state mandates, federal requirements, or the member’s benefit plan may further affect coverage.

Coding and Prior Trial Durations

inv-07: Prior trial duration for acute triptan failures

Required minimum durationMinimum 30-day trial for prior triptan therapies before counting as failures for acute treatment criteria

Applies toNurtec ODT and Ubrelvy acute approval criteria (two triptan failures required) and Zavzpret acute criteria (per-triptan 30-day minimum)

Documentation neededProvider must document drug name(s), dates tried, and duration of each trial (minimum 30 days) to meet requirement

inv-08: Prior trial duration for preventive therapies

Required minimum durationAt least two months trial for prior preventive/prophylactic therapies before counting as failures

State exceptionsConnecticut, Kentucky, and Mississippi require only a 30-day trial for preventive therapies; California does not require a trial of non-CGRP preventive treatments

Provider Actions, Prior Authorization, and Step Therapy

Prior Authorization

Prior Authorization Required

Prior authorization is required. Authorization will be issued for 12 months when criteria are met. State mandates may apply. Any federal regulatory requirements and the member-specific benefit plan coverage may also impact coverage criteria. Other policies and utilization management programs may apply.

Authorization duration: 12 months when criteria met
State mandates and member-specific benefit plan constraints may apply

Step Therapy

Step Therapy Requirements

Step therapy is required — provider must document therapeutic failure, contraindication, or intolerance to specified lower-cost or alternative therapies before approval.

Step therapy: document failure, contraindication, or intolerance to required prior agents

Background

Rimegepant (Nurtec ODT), ubrogepant (Ubrelvy), and zavegepant (Zavzpret) are small‑molecule calcitonin gene–related peptide (CGRP) receptor antagonists approved for acute treatment of migraine; rimegepant (and the oral preventive agent atogepant) also have indications for migraine prevention. Guideline‑recommended acute options include nonsteroidal anti‑inflammatory drugs and migraine‑specific agents such as triptans; the policy requires documented failure, contraindication, or intolerance to specified triptans before approval of the small‑molecule CGRP antagonists for acute use. For prevention, approval requires documented failure, contraindication, or intolerance to at least two listed prophylactic therapies after a trial of at least two months (with state exceptions noted), and prior authorization is issued for 12 months when criteria are met.

Definitions

inv-15: Acute treatment — definition and example agents

DefinitionAcute treatment: use of medication to treat individual migraine attacks

Example agents (documented in policy)Rimegepant (Nurtec ODT), Ubrogepant (Ubrelvy), Zavegepant (Zavzpret)

Authorization notePrior authorization issued for 12 months when criteria are met

inv-16: Preventive treatment — definition and example agents

DefinitionPreventive treatment: ongoing therapy to reduce frequency of migraine attacks

Example agents (documented in policy)Rimegepant (Nurtec ODT) for episodic prevention; Atogepant (Qulipta) for preventive treatment