CurrentColorado Rocky Mountain Health PlansPolicy N/A

Triptans — supply limit (quantity per copayment/home delivery)

Defines quantity limits and approval criteria for triptan agents used for acute migraine treatment for members under the plan; applies to pharmacy benefit quantity overrides and supply limits.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTriptans — supply limit (quantity per copayment/home delivery)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOxford: 1/1/2026

Next Review DateN/A

Key ActionDocument diagnosis of moderate to severe migraine and number/frequency of migraines per month when requesting quantity overrides; physician must acknowledge benefits outweigh risks.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4migraines/month threshold

2migraines/month >1 dose threshold

2 packsImitrex Nasal Spray retail ceiling

6 packsImitrex Nasal Spray home delivery

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Quantity Override (Initial/Continuation)

Quantity requests exceeding the standard per-copayment or home-delivery supply will be approved when ALL of the following are met:

Primary diagnosis: Diagnosis of moderate to severe migraine headaches with or without aura

Frequency/dosing criteria: One of: (a) member has more than four migraines per month (provide number of migraines per month). Approval amount limited to the number of migraines per month the member experiences, up to the ceiling limit; safety of treating an average of >4 headaches in 30 days not established. OR (b) member has more than two migraines per month each requiring more than one dose (provide number of migraines per month). Approval amount limited to the number of migraines per month the member experiences, up to the ceiling limit.

Physician acknowledgment: Physician acknowledges that the potential benefit outweighs the risk associated with the higher dose or quantity

Coding / Key Thresholds

Migraine frequency

Threshold> 4 migraines per month

Required documentationProvider must provide the number of migraines per month

Approval limit noteApproval amount limited to number of migraines per month the member experiences, up to the ceiling limit

Migraines requiring multiple doses

Threshold> 2 migraines per month each requiring more than one dose

Required documentationProvider must provide the number of migraines per month each requiring >1 dose

Approval limit noteApproval amount limited to number of such migraines per month the member experiences, up to the ceiling limit

Provider Actions & Requirements

Denial Risk

Quantity override denial risk

Quantity requests that exceed the plan's standard supply limits will be evaluated against coverage criteria; lack of adequate medical documentation may result in denial of the quantity override request.

Affected products include: Imitrex Nasal Spray, Imitrex Injection, Onzetra Xsail, Tosymra, Zembrace SymTouch, zolmitriptan ODT, Zomig Nasal Spray
Approval limited to the number of migraines per month documented for the member, up to the program ceiling

Documentation Required

Clinical documentation required

Provider must document migraine frequency and dosing needs when requesting quantities above the standard limit. Include the number of migraines per month or the number of migraines per month that require more than one dose, and a physician attestation that the expected benefit outweighs the risks of higher dose/quantity.

If claiming >4 migraines/month, state the number of migraines per month.
If claiming >2 migraines/month that each require >1 dose, state the number of such migraines per month.
Physician attestation required when relying on these criteria

Note

Automated approval processes

Approvals and re-authorizations may be granted automatically based on prior claim or medication history, diagnosis codes (ICD-10), and program claim logic. Use of these automated processes varies by program and therapeutic class.

Automated approval may rely on previous paid claims and submitted diagnosis codes
Programs may differ in whether automated re-authorization is available

Prior Authorization

Quantity override prior authorization — documentation required for requests exceeding standard supply limits

When requesting a quantity override, the request will be reviewed against the coverage criteria for moderate to severe migraine and the specific numeric thresholds. Absence of the required documentation or physician attestation may result in denial.

Coverage criteria include diagnosis of moderate to severe migraine and meeting either the >4 migraines/month criterion or the >2 migraines/month requiring >1 dose criterion.
Approval amounts are limited to treatment of the documented number of migraines per month, up to the program ceiling.

Quantity Limits by Product and Channel

Imitrex Nasal Spray — Quantity limits

Retail limit2 packs (12 units)

Home Delivery limit6 packs (36 units)

ScopeQuantity per copayment/home delivery

Imitrex Injection (4 mg and 6 mg syringes) — Quantity limits

Retail limit4 kits (8 injections)

Home Delivery limit12 kits (24 injections)

Dosage forms4 mg and 6 mg syringes

Imitrex Injection Vials — Quantity limits

Retail limit8 vials

Home Delivery limit24 vials

ScopeQuantity per copayment/home delivery

Onzetra Xsail — Quantity limits

Retail limit8 pouches (16 nose pieces)

Home Delivery limit24 pouches (48 nose pieces)

ScopeQuantity per copayment/home delivery

Tosymra — Quantity limits

Retail limit2 packs (12 units)

Home Delivery limit6 packs (36 units)

ScopeQuantity per copayment/home delivery

Zembrace SymTouch — Quantity limits

Retail limit8 auto-injectors

Home Delivery limit24 auto-injectors

ScopeQuantity per copayment/home delivery

zolmitriptan ODT — Quantity limits

Retail limit8 tablets

Home Delivery limit24 tablets

ScopeQuantity per copayment/home delivery

Zomig Nasal Spray — Quantity limits

Retail limit2 packs (12 units)

Home Delivery limit6 packs (36 units)

ScopeQuantity per copayment/home delivery

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTriptans — supply limit (quantity per copayment/home delivery)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOxford: 1/1/2026

Next Review DateN/A

Key ActionDocument diagnosis of moderate to severe migraine and number/frequency of migraines per month when requesting quantity overrides; physician must acknowledge benefits outweigh risks.

SourceLink

On This Page

OpenPayer

Triptans — supply limit (quantity per copayment/home delivery)

Coverage Criteria

Coding / Key Thresholds

Provider Actions & Requirements

Background

Definitions

Initial Quantity Override Criteria

Re-authorization / Continuation Criteria

Quantity Limits by Product and Channel