Colorado Rocky Mountain Health Plans Gepant Prior Auth

Coverage Criteria for Gepants and CGRP Antagonists

Initial Therapy - Zavzpret

Zavzpret (zavegepant) covered when ALL of the following are met

Zavzpret initial criteria: a) Used for acute treatment of migraine; b) All of the following: (1) History of failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to one oral triptan (document duration) (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan); (2) History of failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to one nasal triptan (sumatriptan nasal spray or zolmitriptan nasal spray) (document drug and date tried); (3) Provider attests the patient is not a candidate for oral or sublingual gepants (e.g., nausea/vomiting, gastroparesis, inability to swallow); c) One of the following: (1) Patient is currently treated with a listed prophylactic therapy (beta-blocker, candesartan, monoclonal antibodies or small-molecule CGRP agents, divalproex, onabotulinumtoxinA, SNRI, topiramate, TCA) OR (2) Patient has <4 migraine days per month OR (3) Patient has >=4 migraine days per month and has contraindication or intolerance to one listed prophylactic therapy; AND d) Medication will not be used in combination with another small-molecule targeting the CGRP receptor ('gepants').see criteria

Authorization issued for 12 months

Initial Therapy - Nurtec ODT (acute and preventive)

Nurtec ODT (rimegepant) covered when ANY ONE of the following sets is met

Nurtec acute pathway: 1) Used for acute treatment of migraine; 2) History of therapeutic failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to two listed triptans (document drug names and dates tried: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan); 3) One of: patient is currently treated with a listed prophylactic therapy (beta-blocker, candesartan, monoclonal antibodies or small-molecule CGRP agents, divalproex, onabotulinumtoxinA, SNRI, topiramate, TCA) OR patient has <4 migraine days per month; AND 4) Medication will not be used in combination with another small-molecule targeting the CGRP receptor ('gepants').see criteria

Authorization for 12 months

Nurtec preventive pathway: 1) Diagnosis of episodic migraines with >=4 migraine days per month; 2) Used for preventive treatment of migraines; 3) History of failure (after a trial of at least two months), contraindication, or intolerance to two specified prophylactic therapies (document drug names and dates tried) OR if >=4 migraine days/month has contraindication/intolerance to one listed prophylactic therapy; 4) Medication will not be used in combination with a monoclonal antibody targeting CGRP or with another small-molecule targeting the CGRP receptor ('gepants').>=4 migraine days/month

Authorization for 12 months

Initial Therapy - Qulipta (partial)

Qulipta (atogepant) covered when ALL of the following are met

Qulipta initial criteria (partial): Diagnosis of migraine consistent with ICHD-3; AND 4 to 7 migraine days per month with <15 headache days per month (policy text continues in full policy)

Document excerpt is partial in source

Qulipta Initial Therapy

Qulipta initial therapy is covered when ALL of the following are met:

Qulipta initial approval: Member has a diagnosis of migraine consistent with ICHD-3

Documentation per policy

Migraine frequency: Member has either: (1) 4-7 migraine days per month with <15 headache days per month OR provider attestation that migraine is the predominant headache diagnosis, OR (2) >=8 migraine days per month4-7 or >=8 migraine days per month

See policy for provider attestation guidance

Prior prophylactic therapy failure: Failure, contraindication, or intolerance to two of the specified prophylactic therapies (document drug names and dates tried). Examples include beta-blockers, candesartan, divalproex, onabotulinumtoxinA, SNRIs, topiramate, tricyclic antidepressants.two therapies

Ubrelvy/Zavzpret Reauthorization

Ubrelvy or Zavzpret reauthorization is covered when ALL of the following are met:

Clinical response: Documentation of positive clinical response to therapy

Authorization will be issued for 12 months

Concomitant gepant exclusion: Medication will not be used in combination with another small-molecule targeting the CGRP receptor ('gepants').

Examples: Nurtec ODT, Qulipta

Nurtec ODT Approval/Reauthorization

Nurtec ODT will be approved or reauthorized when ALL of the following apply depending on indication:

Positive response: Documentation of positive clinical response to therapy

Authorization will be issued for 12 months

Indication-specific conditions: Either: (A) Acute use — use is for acute treatment of migraine AND medication will not be used in combination with another small-molecule targeting the CGRP receptor ('gepants') OR (B) Preventive use — use is for preventive treatment of migraines AND medication will not be used in combination with a monoclonal antibody targeting CGRP or its receptor AND will not be used in combination with another small-molecule targeting the CGRP receptor ('gepants').

See policy for examples of excluded monoclonal antibodies and gepants

Qulipta Reauthorization

Qulipta reauthorization is covered when ALL of the following are met:

Positive response: Documentation of positive clinical response to therapy

Authorization will be issued for 12 months

Concomitant CGRP exclusion: Medication will not be used in combination with a monoclonal antibody targeting CGRP or with another small-molecule gepant.

Examples listed in policy (Aimovig, Ajovy, Emgality, Vyepti; Nurtec ODT, Ubrelvy, Zavzpret)

The policy prohibits concurrent use of a study medication with another small-molecule CGRP receptor antagonist (a "gepant"). Examples listed in the policy include Nurtec ODT, Qulipta, Zavzpret, and Ubrelvy. Providers must ensure the requested medication will not be used in combination with any other gepant when documenting the request.

Concomitant therapy with monoclonal antibody CGRP-targeted agents or with other small-molecule CGRP receptor antagonists is excluded. The policy explicitly lists monoclonal CGRP agents (e.g., Aimovig, Ajovy, Emgality, Vyepti) and reiterates that the medication must not be used together with other gepants (examples: Nurtec ODT, Ubrelvy, Zavzpret, Qulipta). Requests that indicate combined use with these agents will not meet coverage criteria.

Coverage is subject to member-specific benefit design and applicable state or federal mandates. Where the benefit plan or regulatory requirements do not permit a therapy, the medication may not be covered even if it otherwise meets the clinical criteria. Providers should verify member benefits and document any applicable state-specific exceptions when submitting authorization requests.

Coding, Eligibility Thresholds, and Clinical Thresholds

Migraine episode / triptan trial requirement

RequirementHistory of therapeutic failure after at least 3 migraine episodes and a minimum 30-day trial of an acute-use triptan (document drug name and dates tried)

Triptan examplesalmotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan (documented)

ApplicabilityApplies to acute-use gepant initial authorization pathways (e.g., Ubrelvy, Nurtec ODT acute) per policy criteria

Preventive migraine frequency

Preventive threshold>= 4 migraine days per month

Related useUsed to determine eligibility for preventive indication of Nurtec ODT and for meeting prophylactic criteria

Prior Authorization, Documentation, and Step Therapy Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required. Approvals are issued for 12 months when criteria are met for each product (Ubrelvy, Zavzpret, Nurtec ODT, Qulipta).

Authorization duration: 12 months for Ubrelvy, Zavzpret, Nurtec ODT, and Qulipta.

Documentation Required

Required Documentation of Prior Trials

Initial and reauthorization requests must include documentation of prior trials. For acute-use agents (Ubrelvy, Zavzpret, Nurtec ODT when used acutely) document the drug names and dates tried showing therapeutic failure after at least 3 migraine episodes and minimum trial durations (typically ≥30 days). For preventive therapy (Nurtec ODT preventive indication, Qulipta) document the drug name and dates tried showing failure, contraindication, or intolerance to the required prophylactic therapies and that each preventive trial lasted at least two months where specified.

Document each prior trial: drug name, start/end dates, and reason for discontinuation (failure, intolerance, contraindication).

Definitions and Background

Small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists, commonly called gepants, include agents used for acute migraine treatment such as rimegepant, ubrogepant, and zavegepant. Among these, rimegepant (Nurtec ODT) and the small-molecule atogepant (Qulipta) also have preventive indications. Gepants provide an oral or intranasal, targeted option alongside standard acute therapies (NSAIDs, acetaminophen, triptans) and may be considered when patients have contraindications to or have failed other treatments.

Gepants (small‑molecule CGRP receptor antagonists)

DefinitionGepants are small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists used for acute or preventive migraine treatment

ExamplesNurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), Zavzpret (zavegepant)

IndicationsSome gepants are indicated for acute treatment (rimegepant, ubrogepant, zavegepant); rimegepant and atogepant also have preventive indications

ICHD-3 (diagnostic standard)

OpenPayer

Prior authorization and medical necessity criteria for Nurtec ODT, Qulipta, Ubrelvy, and Zavzpret (CGRP receptor antagonists)

Coverage Criteria for Gepants and CGRP Antagonists

Coding, Eligibility Thresholds, and Clinical Thresholds

Prior Authorization, Documentation, and Step Therapy Requirements

Definitions and Background