CurrentColorado Rocky Mountain Health PlansPolicy N/A

Authorization form for ubrogepant (Ubrelvy) and rimegepant (Nurtec) for migraine

This document is an authorization and reauthorization form used by providers to request coverage for Ubrelvy (ubrogepant) or Nurtec (rimegepant) for adult beneficiaries with migraine; it outlines required patient, prescriber, drug, and clinical response information. It affects prescribers and prior authorization staff processing migraine treatment requests.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAuthorization form for ubrogepant (Ubrelvy) and rimegepant (Nurtec) for migraine

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form including beneficiary and prescriber details, drug information, answers to initial (1-6) or reauthorization (1-9) questions, and obtain prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6initial authorization checklist questions

3reauthorization questions required

18+minimum beneficiary age

>=15headache frequency threshold

Coverage Criteria for Ubrogepant / Rimegepant

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inv-01: Initial Therapy

Covered when ALL of the following are met for initial authorization:

Initial authorization criteria: Beneficiary is 18 years of age or older.

Initial authorization criteria: Beneficiary has a diagnosis of migraine (with or without aura).

Initial authorization criteria: Documented headache frequency of 15 or more headache days per month over the past 6 months.>= 15 days/month

Initial authorization criteria: Beneficiary will not use ubrogepant/rimegepant concurrently with a strong CYP3A4 inhibitor (concurrent use is contraindicated).

Initial authorization criteria: Beneficiary does not have end-stage renal disease with creatinine clearance (CrCl) less than 15 ml/min.CrCl >= 15 ml/min

Initial authorization criteria: Beneficiary has tried and failed, or has a contraindication to, two or more preferred triptans.

inv-02: Continuation / Reauthorization

Reauthorization covered when ALL of the following are met:

Reauthorization criterion: Beneficiary continues to meet the initial authorization criteria (questions 1-6).

Reauthorization criterion: Prescriber documents resolution in headache pain or a reduction in headache severity as assessed by the prescriber.clinical judgment

Reauthorization criterion: Prescriber documents absence of treatment‑restricting adverse effects, or documents that adverse effects have been addressed.

Operational note: Prescriber signature and date are required on the reauthorization form to certify accuracy of responses.

The form explicitly queries concurrent use of Ubrelvy/Nurtec with a strong CYP3A4 inhibitor. A positive response to that question contraindicates coverage per the form and will preclude authorization. The form also asks whether the beneficiary has end‑stage renal disease with a creatinine clearance (CrCl) <15 ml/min; presence of CrCl < 15 ml/min is an exclusionary condition. Providers should not request coverage if either of these conditions is present unless additional supporting clinical documentation justifies an exception.

Initial and reauthorization eligibility is determined by the form questions. Disqualifying or required items include: beneficiary age under 18 years (question 1); absence of a migraine diagnosis (question 2); failure to meet the headache frequency threshold of 15 or more headache days per month over the past 6 months (question 3); planned concurrent use with a strong CYP3A4 inhibitor (question 4); presence of end‑stage renal disease with CrCl < 15 ml/min (question 5); and not having tried and failed, or having a contraindication to, 2 or more preferred triptans (question 6). For reauthorization, the prescriber must also attest that the beneficiary continues to meet questions 1–6 and document clinical benefit (resolution or reduction in headache severity) and absence of treatment‑restricting adverse effects (questions 7–9).

Key Thresholds and Coding Values

inv-05: Headache frequency threshold

Headache frequency threshold15 or more headache days per month over the past 6 months

Assessment periodMeasured over the past 6 months as asked on the form

Question referenceForm question 3 asks: 'Does the Beneficiary have a headache frequency of 15 or more headache days per month over the past 6 months?'

inv-06: Age threshold

Age threshold>= 18 years

Form itemForm question 1: 'Is the Beneficiary 18 years of age or older?'

Coverage implicationBeneficiary must be 18 years or older for eligibility

inv-07: Renal function threshold

Renal function thresholdCreatinine clearance (CrCl) < 15 ml/min

Clinical definitionDescribed on form as end-stage renal disease with CrCl less than 15 ml/min

Form itemForm question 5 asks about ESRD with CrCl <15 ml/min

Provider Actions, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Form Completion Required

Prior Authorization Form Completion Required: Prior authorization requests must include completion of the provided form fields with beneficiary and prescriber information, drug details, and answers to the clinical questions for initial or reauthorization requests.

Beneficiary demographics (name, ID, DOB, gender)
Prescribing provider NPI and requester contact information
Drug name, strength, quantity per 30 days, and length of therapy

Documentation Required

Required Documentation on the Form

Required Documentation on the Form: The prescriber must submit the completed form containing the following information. Incomplete forms may delay processing or result in denial.

Beneficiary last name, first name, member ID, date of birth, and gender
Prescribing provider NPI and requester contact name, phone, address
Drug name, strength, quantity per 30 days, and selected length of therapy (e.g., up to 30, 60, 90, 120, 180, 365 days)
Prescriber signature and date (signature is mandatory)

Step Therapy

Triptan Trial Requirement

Triptan Trial Requirement: For initial requests, the prescriber must indicate that the beneficiary has tried and failed, or has a contraindication to, two or more preferred triptans. This must be documented on the prior authorization form (question 6) to meet eligibility for coverage.

Question 6 on the form: Has the beneficiary tried and failed, or have a contraindication to 2 or more preferred triptans? — Yes/No

Denial Risk

Triggers for Denial

Triggers for Denial: Requests may be denied if any of the following apply. Confirm all criteria and required therapy documentation before submission to avoid denial.

Beneficiary is under 18 years of age (form question 1)
No documented diagnosis of migraine (form question 2)
Headache frequency below required threshold (less than 15 headache days per month over the past 6 months) (form question 3)
Lack of documentation that the beneficiary tried and failed or has contraindications to two or more preferred triptans (form question 6)
Incomplete or unsigned prior authorization form (missing prescriber signature or required fields)

Background

This authorization form is used to request coverage for the acute migraine therapies ubrogepant (Ubrelvy) or rimegepant (Nurtec) in adults. It collects beneficiary and prescriber details, drug name/strength/quantity/length of therapy, and structured clinical responses to establish eligibility: age (≥18 years), migraine diagnosis, chronicity (headache frequency ≥15 days/month over 6 months), renal function (CrCl <15 ml/min is exclusionary), concurrent strong CYP3A4 inhibitor use, and prior triptan treatment history. Responses to these items determine initial approval; for reauthorization the form also requires prescriber attestation of continued criteria fulfillment and documentation of clinical response and tolerability.

Definitions and Clinical Terms

inv-13: Chronic headache frequency

Chronic headache frequencyDocumented headache frequency of 15 or more headache days per month over the past 6 months as asked in the form

Form locationQuestion 3 on the initial/reauthorization section

Role in criteriaRequired affirmative response for initial authorization

inv-14: Severe renal impairment

Severe renal impairmentEnd-stage renal disease with creatinine clearance (CrCl) less than 15 ml/min as queried on the form

Form locationQuestion 5 on the initial/reauthorization section

Coverage impactPresence of ESRD with CrCl <15 ml/min is exclusionary per the form

inv-15: Triptan failure

Triptan failure requirementHistory of trying and failing, or having a contraindication to, two or more preferred triptans

Form itemQuestion 6 asks if the beneficiary has tried and failed or has a contraindication to 2 or more preferred Triptans

Use for initial authorizationAffirmative answer required for initial coverage determination