Migraine Acute Treatment Agents Prior Authorization
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This form governs prior authorization requirements and quantity/daily dose limit requests for acute migraine treatments (triptans, gepants, ditans, ergot alkaloids, NSAIDs, and combination products) for Geisinger Health Plan members. It affects prescribers submitting new or renewal requests and those seeking exceptions to DHS-established quantity/dose limits.
No material clinical or coverage changes in this revision.
Coverage Criteria for Acute Migraine Treatments
Initial requests — class-specific prior trial/contraindication requirements
Covered when the following class-specific conditions are met and documentation is submitted:
Supported by form checkboxes
Form lists examples (Cafergot, D.H.E., Migranal)
Examples include Elyxyb, diclofenac powder packet
Renewal requests
Covered upon renewal when the following are met:
Required checkbox on renewal section
Quantity limits / Daily dose limits exceptions
Requests exceeding DHS quantity/daily dose limits are covered only when documentation meets all of the following:
Form asks prescriber specialty and asks for supporting references
Multiple checkboxes provided for preventive therapy options
Requests that do not include documentation supporting an exception to DHS quantity or daily dose limits or that fail to demonstrate specialist support or literature justification are not eligible for an exception. The form requires submission of documentation showing either that the medication was prescribed by a neurologist or a UCNS‑certified headache specialist, or that the requested quantity/dose/frequency is supported by current medical compendia or peer‑reviewed literature; if neither is provided, the request may be denied. For quantity/dose exception requests related to acute migraine treatment, the form additionally requires documentation of evaluation for medication overuse and evidence regarding preventive therapy or attempts at preventive agents as applicable.
DHS Quantity and Dose Limits
Provider Requirements and Submission Instructions
Prior authorization required for acute migraine agents and DHS limit exceptions
Prior authorization is required for all new and renewal requests for migraine acute treatment agents and for any request that exceeds DHS quantity/daily dose limits; complete the appropriate INITIAL or RENEWAL section and provide required supporting documentation.
- Complete INITIAL or RENEWAL section on the form.
- If request exceeds DHS limits, also complete the QUANTITY LIMITS/DAILY DOSE LIMITS section and provide supporting documentation.
Document required step therapy / preferred-agent trials by drug class
Document prior trials, intolerances, or contraindications to preferred agents as required by drug class: e.g., gepants require trial and failure of at least 2 triptans (or documented contraindication/intolerance); non-preferred agents require failure/intolerance/contraindication to preferred agents as listed on the form.
- Gepants: Tried and failed ≥2 triptans or has contraindication/intolerance; non-preferred gepants require failure/intolerance/contraindication to preferred gepants.
- Ditans: Tried and failed or has contraindication/intolerance to preferred triptans; non-preferred ditans require failure/intolerance/contraindication to preferred migraine acute agents.
- Non-preferred triptans/NSAIDs/ergot alkaloids/combination products: Document required prior failures or clinical reasons per the form.
Submit completed PA form with supporting clinical documentation
Submit the completed Migraine Acute Treatment Agents Prior Authorization Form with all required clinical documentation demonstrating diagnosis, prior therapies/trials or contraindications/intolerances, quantity/dose justification, and any specialist certification; send via PromptPA or fax to Geisinger Health Plan.
- Include diagnosis and DX code as requested on the form.
- Attach documentation of prior trials/intolerances/contraindications and supporting literature when exceeding DHS limits.
- Submit via PromptPA (https://ghp.promptpa.com) or fax to 570-271-5610.
Authorization required when exceeding DHS quantity/daily dose limits
All requests that exceed DHS-established quantity limits/daily dose limits require prior authorization and must include documentation that the requested quantity/dose/frequency is supported by current medical compendia or peer‑reviewed literature or that the medication is prescribed by a neurologist or UCNS‑certified headache specialist.
- If exceeding DHS limits, indicate whether prescriber is neurologist or UCNS‑certified headache specialist on the form.
- Provide supporting references from medical compendia or peer‑reviewed literature to justify requested quantity/dose/frequency.
Denial risk if required trials, contraindications, or DHS-justifying documentation are not provided
Requests for non-preferred agents or agents subject to step therapy will be denied if the form does not document required prior trials, contraindications, or intolerances; similarly, requests exceeding DHS limits risk denial if supporting specialist certification or literature is not provided.
- Missing documentation of required prior failures/intolerances/contraindications to preferred agents may lead to denial.
- Failure to provide specialist certification or medical literature to justify quantity/dose when exceeding DHS limits may lead to denial.
Background
This prior authorization form applies to acute migraine pharmacologic options including gepants (small‑molecule CGRP inhibitors), ditans (5‑HT1 receptor agonists), triptans, ergot alkaloids, oral NSAIDs, and combination products (e.g., triptan‑NSAID combinations). Coverage and renewal criteria in the form set class‑specific requirements such as prior trials of preferred agents, documented contraindications or intolerances, and documentation required when requesting quantities or doses that exceed DHS limits.
Key Definitions
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