CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization / exception request form for non-preferred drugs and quantity overrides (migraine therapies)

A provider-facing prior authorization and exception request form used to request coverage for non-preferred medications or to exceed quantity limits (notably migraine therapies) for Colorado Rocky Mountain Health Plans beneficiaries.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization / exception request form for non-preferred drugs and quantity overrides (migraine therapies)

Policy CodePolicy N/A

Change TypeMinor or no change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and sign the prior authorization form with beneficiary and prescriber information, drug details, documentation of two failed preferred drugs or contraindication, and clinical justification.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

formdocument type

non-preferred + overrideuse cases

12/30dbase limit

requires signatureattestation

Coverage and Approval Criteria

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Non-preferred drug approval criteria

Covered when ALL of the following are met (non-preferred drug request):

Non-preferred drug initial criteria: Provider completes beneficiary and prescriber details; specifies drug, strength, quantity, and length of therapy; documents failure of two preferred drugs OR documents allergic reaction, drug-to-drug interaction, prior therapeutic failure/unacceptable side effect, clinical contraindication/co-morbidity/unique patient circumstance, age-specific indication, unique FDA or peer-reviewed literature-supported indication, or unacceptable clinical risk associated with therapeutic change; prescriber signature required.

Form requires listing failed preferred drugs and explanation for selected justification(s).

Quantity override approval criteria

Covered when ALL of the following are met (quantity override >12/30 days):

Quantity override criteria: Patient has a diagnosis of migraine or cluster headache; headache frequency/severity documented (e.g., >6 moderate or severe headaches when checked); documentation of prior NSAID therapy in past year or documented contraindication/allergy to NSAIDs; documentation of current use of or failure of migraine preventative therapy (including statement that no clinical benefit after ≥90‑day trial at maximum tolerated dose when applicable) or documented contraindication/adverse reaction to preventative medications; absence of contraindicated conditions (ischemic heart disease, peripheral vascular disease, cerebrovascular disease, ischemic bowel disease, hemiplegic migraine); no MAOI use in past 2 weeks; no concurrent (or within 24 hours) use of ergotamine-containing/ergot-type medications or another 5‑HT1 agonist; absence of uncontrolled hypertension or basilar migraine; prescriber has reviewed DHB evidence‑based migraine recommendations; prescriber signature required.12 per 30 days

Checklist items on form; prescriber signature is mandatory.

Per the form checklist, patients with any of the following conditions are identified as contraindications for quantity-override requests and may preclude approval: Ischemic heart disease, peripheral vascular disease, cerebrovascular disease, ischemic bowel disease, or hemiplegic migraine. The form also screens for recent MAOI use within the past 2 weeks and for recent or concurrent use of ergotamine-containing agents or other 5-HT1 agonists within 24 hours, which are contraindications for approvals to exceed the standard quantity limit.

Requests lacking adequate documentation will risk denial. Specifically, non-preferred drug requests must document either failure of two preferred drugs (with drugs listed and reasons such as allergic reaction, drug–drug interaction, therapeutic failure, or unacceptable side effects) or provide clear clinical justification (e.g., contraindication, age-specific indication, FDA/literature-supported unique indication, or unacceptable risk with therapeutic change). For quantity-override requests, the form requires documentation of diagnosis (migraine or cluster headache), headache frequency/severity, prior NSAID therapy or documented contraindication, current or prior preventive therapy trials (including a 90-day trial at maximum tolerated dose when applicable), and a signed prescriber attestation; absence of these items may render the request not medically necessary.

What the Provider Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-preferred drugs and for requests that exceed quantity limits. The prescriber must complete the beneficiary and prescriber information, provide drug details, indicate length of therapy, and give a clinical rationale consistent with step-therapy and quantity-override requirements. Prescriber signature is mandatory.

Prior authorization required for non-preferred drugs and quantity limit exceedances (requests > 12 per 30 days).
Completed beneficiary and prescriber information must be submitted (including Prescribing Provider NPI and requester contact).
Include drug name, strength, quantity per 30 days, and selected length of therapy.
Prescriber signature is mandatory on the request form.

Denial Risk

Non-Preferred Drug Denial Triggers

For requests for a non-preferred drug, the form must document prior trials or contraindications. Missing required documentation is a basis for denial.

Document failure of two preferred drugs and list the specific preferred agents tried.
If not due to failure, provide clear documentation of an allergic reaction, drug–drug interaction, unacceptable side effect, therapeutic failure, clinical contraindication/co-morbidity, age-specific indication, FDA/peer-reviewed literature support for a unique indication, or unacceptable clinical risk associated with therapeutic change.
A simple statement without supporting clinical detail (e.g., listing agents without dates/doses or lacking explanation of reaction/failure) may lead to denial.

Denial Risk

Quantity Override Denial Triggers

Requests to exceed the standard quantity limit (more than 12 per 30 days) must include headache- and treatment-specific answers to the checklist. Incomplete or unsupported responses are grounds for denial.

Must confirm diagnosis of migraine or cluster headache when requesting >12 per 30 days.
Document frequency of moderate or severe headaches (e.g., >6) and prior NSAID therapy in the past year or contraindication to NSAIDs.
Report current use of migraine preventative therapy, any contraindication or adverse reaction to preventatives, and whether a >=90-day trial at maximum tolerated dose failed to provide clinical benefit.
Disclose comorbid diagnoses (ischemic heart disease, peripheral vascular disease, cerebrovascular disease, ischemic bowel disease, hemiplegic migraine) and recent MAO inhibitor use or potential concurrent use of ergotamine or other 5‑HT1 agonists.
Confirm review of evidenced-based migraine treatment recommendations. Missing answers to these checklist items or failure to substantiate with clinical detail may result in denial.

Step Therapy

Step Therapy / Failure Requirement

Prescriber must attest to step-therapy requirements when applicable and supply the clinical rationale if exceptions are claimed.

When step therapy applies, attest that the patient failed two preferred drugs or provide a documented contraindication, allergy, or drug interaction that prevents use of preferred agents.
Provide dates, doses, and clinical outcomes for prior therapies to support the step-therapy exception.

Key Definitions

Exceeding 12 per 30 days — quantity limit definition

DefinitionRequests to exceed the plan's set quantity limit of 12 doses per 30 days require completion of the 'Request for Exceeding Quantity Limit (Exceeding 12 per 30 days)' checklist on the form.

Required documentationDiagnosis (migraine or cluster headache), headache frequency/severity, prior NSAID therapy or contraindication, preventative therapy history and trial duration, contraindications and medication interactions (MAOI, ergotamines, other 5-HT1 agonists).

Contraindications to approvalIschemic heart disease, peripheral vascular disease, cerebrovascular disease, ischemic bowel disease, hemiplegic migraine, recent MAOI use, concurrent ergotamine or 5-HT1 agonist use.

Non-preferred drug — definition

DefinitionA non-preferred drug is a medication not on the plan's preferred drug list; coverage requires documentation justifying use over preferred alternatives (e.g., failure of two preferred drugs, allergic reaction, drug–drug interaction, contraindication, age-specific indication, FDA/literature-supported indication, or unacceptable risk with therapeutic change).

Approval requirementPrescriber must list failed preferred drugs and provide clinical rationale or cite contraindication/allergy/interaction on the form.

Prescriber attestationPrescriber signature is required on the request form.

Preferred drug failed	Reason
(line for first preferred drug)_________________________________________	Allergic Reaction (check box) / Drug-to-drug interaction (describe) / Prior therapeutic failure (provide clinical info)
(line for second preferred drug)___________________	Allergic Reaction (check box) / Drug-to-drug interaction (describe) / Prior therapeutic failure (provide clinical info)

OpenPayer

Prior authorization / exception request form for non-preferred drugs and quantity overrides (migraine therapies)

Coverage and Approval Criteria

Coding and Quantity Limits

What the Provider Must Do

Background and Purpose

Key Definitions

Step Therapy Requirements

Quantity Limits and Applicability