ModifiedColorado Rocky Mountain Health PlansPolicy N/A

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

Prior authorization and medical necessity criteria for coverage of rimegepant (Nurtec ODT), atogepant (Qulipta), ubrogepant (Ubrelvy), and zavegepant (Zavzpret) for adults with migraine. Applies to Colorado Rocky Mountain Health Plans members governed by this UnitedHealthcare Pharmacy Clinical Pharmacy Program.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCGRP receptor antagonists and gepants coverage criteria (Nurtec ODT, Qulipta, Ubrelvy, Zavzpret)

Policy CodePolicy N/A

Change TypeLanguage update to concomitant CGRP useprior material revisions

Effective DateJun 1, 2026

Next Review DateMar 1, 2026

Key ActionObtain prior authorization; approvals issued for 12 months when clinical criteria are met.

SourceLink

POLICY UPDATE CHANGES

Updated language on concomitant CGRP use.

Removed notation that Qulipta is typically excluded from coverage and removed CGRP step for Qulipta.

Added Zavzpret and updated prophylactic therapy lists and steps for Qulipta (episodic and chronic).

4medications covered

12authorization duration (months)

>=3acute-use trial threshold

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preventive trial minimum (months)

4-7 / >=8migraine days categories

Coverage Criteria for Gepants (Nurtec ODT, Qulipta, Ubrelvy, Zavzpret)

Qulipta (atogepant) — Initial Authorization (start)

Approved when ALL of the following are met

Qulipta initial criteria (start): 1) Diagnosis of migraine consistent with The International Classification of Headache Disorders, 3rd edition (ICHD-3); 2) One of the following migraine frequency categories: a) 4 to 7 migraine days per month with <15 headache days per month or provider attestation that migraine is the predominant headache diagnosis, OR b) ≥8 migraine days per month; (additional criteria continue in full initial approval set).

Initial Therapy

Qulipta initial approval when ALL of the following are met

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

Migraine frequency: Either 4-7 migraine days/month with <15 headache days/month or provider attestation that migraine is the predominant headache diagnosis, OR ≥8 migraine days/month.4-7 or >=8

Prophylactic therapy trials: Failure, contraindication, or intolerance to two prophylactic therapies after a trial of at least two months (document medication name and date tried).2 therapies; 2 months each

Enumerated options include selected beta-blockers, candesartan, divalproex, onabotulinumtoxinA, SNRIs, topiramate, tricyclic antidepressants.

Concomitant therapy restrictions: Medication must not be used in combination with a monoclonal antibody targeting CGRP or its receptor, and must not be used with another small-molecule CGRP receptor antagonist ('gepants').

Examples listed in policy.

Ubrelvy or Zavzpret Reauthorization

Reauthorization when BOTH of the following are met

Positive response: Documentation of positive clinical response to therapy.

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

Examples: Nurtec ODT, Qulipta.

Nurtec ODT Acute and Preventive Use

Nurtec ODT approval when criteria vary by indication

Positive response: Documentation of positive clinical response to therapy is required for reauthorization.

Acute use path: If used for acute treatment: medication will not be used in combination with another small-molecule targeting the CGRP receptor ('gepants').

Preventive use path: If used for preventive treatment: medication will not be used in combination with a monoclonal antibody targeting CGRP or its receptors, and will not be used with another small-molecule CGRP receptor antagonist ('gepants').

Qulipta Reauthorization

Qulipta reauthorization when BOTH of the following are met

Positive response: Documentation of positive clinical response to therapy.

Concomitant therapy restrictions: Medication must not be used in combination with a monoclonal antibody targeting CGRP or its receptor, and must not be used in combination with another small-molecule CGRP receptor antagonist ('gepants').

The policy expressly prohibits concomitant use of small-molecule CGRP receptor antagonists. Medication will not be used in combination with another small-molecule targeting the CGRP receptor ('gepants') (examples listed in policy include Nurtec ODT, Qulipta, Ubrelvy, Zavzpret), and this restriction applies across acute-use and preventive pathways for agents covered under this policy.

For Nurtec ODT when requested under the preventive pathway, the policy additionally requires that the drug not be used with a monoclonal antibody targeting CGRP or its receptor. In practice this means the preventive pathway disallows combination therapy with both another gepant and with CGRP-targeting monoclonal antibodies.

Historically, the policy documentation noted that Ajovy is typically excluded from coverage. This appears as a legacy coverage remark in the source policy language and is retained here as a historical note about prior program edits.

Change-control history in the policy record documents multiple prior edits (including periods where certain agents were noted as excluded); readers should consult plan-specific benefit rules and more recent change logs for the current formulary position.

Use of a gepant in combination with a monoclonal antibody that targets CGRP (or its receptor) or with another small-molecule CGRP receptor antagonist is explicitly disallowed by the policy and will be a basis for non-approval. The policy language states that medication will not be used in combination with a monoclonal antibody targeting CGRP or its receptor (examples: Aimovig, Ajovy, Emgality, Vyepti) and likewise will not be used in combination with another small-molecule targeting the CGRP receptor ('gepants') (examples: Nurtec ODT, Ubrelvy, Qulipta, Zavzpret).

Requests that document concurrent use of any of these listed biologic CGRP agents or another gepant should be denied as non-compliant with the coverage criteria.

Coding and Usage Thresholds

Acute-use trial requirement — Failure after at least 3 migraine episodes and a minimum 30-day trial

RequirementHistory of therapeutic failure after at least 3 migraine episodes and a minimum 30-day trial (document name and date tried).

Applies toAcute-use gepants (e.g., ubrogepant, rimegepant, zavegepant) when requested for acute migraine treatment.

DocumentationProvider must document medication names tried, dates of trials, duration, and reason for failure, contraindication, or intolerance.

Preventive-use trial duration — Trial of at least 2 months of prophylactic therapies

Minimum durationTrial of at least 2 months for each prophylactic therapy before counted as a failure (document name and date tried).

Number required

Provider Actions, Documentation, and Authorization

Prior Authorization

Prior Authorization Required; Duration

Prior authorization is required for these medications. Initial authorizations and reauthorizations must meet the specific clinical criteria in the policy and, when criteria are met, approvals will be issued for 12 months.

Initial authorization and reauthorization require documentation that the applicable clinical criteria are met.
Authorizations (initial and reauthorization) will be issued for 12 months when criteria are satisfied.

Denial Risk

Requests May Be Denied If Required Documentation or Trials Are Missing

Requests may be denied if the provider does not document required prior trials or if the patient has not had the required failure, contraindication, or intolerance as specified by the policy (for example, failure after at least 3 migraine episodes and a minimum 30-day trial for acute therapies or specified duration for preventive trials).

Background and Drug Class Information

Nurtec ODT (rimegepant), Ubrelvy (ubrogepant), and Zavzpret (zavegepant) are small-molecule CGRP receptor antagonists (gepants) used for acute treatment of migraine. The policy identifies all three as indicated for acute migraine therapy.

Additionally, Nurtec ODT and Qulipta (atogepant) have regulatory indications for preventive treatment of episodic migraine in adults; Nurtec ODT is included with both acute and preventive pathways in this policy, and Qulipta is addressed specifically for preventive use.

Clinical selection and step requirements in the policy reference guideline-concordant acute options (e.g., NSAIDs, acetaminophen, triptans) and enumerate prophylactic therapies for preventive use, reflecting differences in when acute versus preventive gepant therapy is appropriate.

Definitions and Key Terms

Gepants / CGRP receptor antagonists — Small-molecule CGRP receptor antagonists used for acute (ubrogepant, rimegepant, zavegepant) and preventive indications

Acute-use agentsUbrogepant (Ubrelvy), rimegepant (Nurtec ODT), zavegepant (Zavzpret) — indicated for acute treatment of migraine.

Preventive-use agentsRimegepant (Nurtec ODT, oral disintegrating tablet) and atogepant (Qulipta) have preventive indications.

Concomitant usePolicy prohibits use in combination with another small-molecule CGRP receptor antagonist ('gepants').

Migraine days per month — Categories used: 4-7 migraine days per month (with <15 headache days or provider attestation of predominant migraine diagnosis) or >=8 migraine days/month

Category A4–7 migraine days/month with <15 headache days/month or provider attestation that migraine is the predominant headache diagnosis.

Policy Revision History

2026-03-01annual_reviewLatest

Annual review updated language on concomitant CGRP use.

2025-02-01footnote_added

Added footnote for California-specific requirement.

2024-06-01policy_update

Policy updated to remove notation that Qulipta is typically excluded from coverage and removed the CGRP step for Qulipta.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCGRP receptor antagonists and gepants coverage criteria (Nurtec ODT, Qulipta, Ubrelvy, Zavzpret)

Policy CodePolicy N/A

Change TypeLanguage update to concomitant CGRP useprior material revisions

Effective DateJun 1, 2026

Next Review DateMar 1, 2026

Key ActionObtain prior authorization; approvals issued for 12 months when clinical criteria are met.

SourceLink

On This Page

Failure, contraindication, or intolerance to two prophylactic therapies is required for preventive-use approval (document trials).

Examples of prophylacticsSelected options include betablockers (atenolol, metoprolol, nadolol, propranolol, timolol), candesartan, divalproex sodium.

Migraine days per month — 4-7 days; >=8 days

Category 1 (episodic)4 to 7 migraine days per month AND at least one of: <15 headache days/month OR provider attestation that migraine is the predominant headache diagnosis.

Category 2 (frequent/chronic)Greater than or equal to 8 migraine days per month.

Use in Qulipta criteriaMigraine frequency category determines prophylactic trial requirements and eligibility for atogepant (Qulipta).

Denials possible when documentation of medication name, date tried, duration of trial, and reason for failure/contraindication/intolerance is absent.

For acute therapy step requirements, a history of therapeutic failure after at least 3 migraine episodes and a minimum 30-day trial is required (unless otherwise noted by state-specific mandates).

For preventive therapy (e.g., Qulipta, Nurtec preventive use), trials of at least two months are required for listed prophylactic therapies unless state-specific exceptions apply.

Billing Rule

Concomitant CGRP Therapy Prohibited

Concomitant use of these agents with other CGRP-targeted therapies is prohibited. The medication will not be approved for use in combination with a monoclonal antibody targeting CGRP or its receptor or with another small-molecule CGRP receptor antagonist.

Do not prescribe in combination with monoclonal antibody CGRP therapies (e.g., Aimovig, Ajovy, Emgality, Vyepti).
Do not prescribe in combination with another 'gepant' (e.g., Nurtec ODT, Qulipta, Ubrelvy, Zavzpret).

Documentation Required

Prophylactic Trial Documentation Required

Providers must document trials of prophylactic therapies when required for initial approval of preventive indications. Documentation must include medication name and date tried; include duration and reason for failure, contraindication, or intolerance where applicable.

Document the medication name and date tried for two prophylactic therapies (or document contraindication/intolerance) for Qulipta initial requests.
For Nurtec ODT preventive use and other preventive criteria, document trials (name and date tried) of the specified prophylactic therapies and reasons for discontinuation if applicable.
Include duration of trial (e.g., at least two months for preventive trials) and reason for failure, intolerance, or contraindication.

Step Therapy

Step Therapy and Provider Documentation Requirements

Step therapy is required: patients must have trialed specified lower-cost or guideline-recommended options prior to approval of the requested agent. Providers must document the medication names tried, dates of trials, duration, and reason for failure, contraindication, or intolerance.

Acute treatment step: history of therapeutic failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to the specified triptans (list provided in policy) and, where applicable, failure of nasal triptan options.
Preventive step: failure (after a trial of at least two months), contraindication, or intolerance to two of the listed prophylactic therapies (e.g., beta-blockers, candesartan, divalproex, topiramate, tricyclics, SNRIs, Botox where applicable).
Providers must include medication names, dates tried, duration of each trial, and reason for failure/intolerance/contraindication on prior authorization requests.

Category B≥8 migraine days/month.

ImplicationMigraine day category is used to determine eligibility and required prophylactic therapy trials (e.g., Qulipta requires documentation tied to these categories).

2023-07-01policy_update

Added Zavzpret and expanded Qulipta criteria to allow both episodic and chronic migraines and updated prophylactic therapy examples.

2020-03-01program_start

Program established with initial prior authorization/medical necessity criteria for Nurtec ODT, Qulipta, Ubrelvy, and Zavzpret.