CurrentGeorgia Department of Community HealthPolicy N/A

Georgia Medicaid Fee-for-Service Antimigraine Agents (Other) — Prior Authorization Criteria

Customize your policy alerts

Sign up for all Georgia Department of Community Health policy alerts

Know when Georgia Department of Community Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines prior authorization requirements and clinical criteria for coverage of select antimigraine agents under Georgia Medicaid Fee-for-Service, affecting prescribers and pharmacists seeking PA for listed medications.

Policy Summary

PayerGeorgia Department of Community Health

PolicyAntimigraine agents prior authorization (other agents)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization through OptumRx and document required prior trials or specialist consultation per agent-specific criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

VariesLength of authorization

2Triptan trial requirement

4+Episodic threshold

15+Chronic threshold

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentGeorgia Department of Community HealthPolicy N/A

Georgia Medicaid Fee-for-Service Antimigraine Agents (Other) — Prior Authorization Criteria

Customize your policy alerts

Sign up for all Georgia Department of Community Health policy alerts

Know when Georgia Department of Community Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerGeorgia Department of Community Health

PolicyAntimigraine agents prior authorization (other agents)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization through OptumRx and document required prior trials or specialist consultation per agent-specific criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

VariesLength of authorization

2Triptan trial requirement

4+Episodic threshold

15+Chronic threshold

Medication-Specific Coverage Criteria

inv-01: Aimovig initial coverage

Aimovig (erenumab-aooe) — covered when ALL of the following are met

Age/Indication: Member is 18 years of age or older AND diagnosis of episodic migraine with >= 4 migraine days per month OR diagnosis of chronic migraine with >= 15 headache days per month for at least 3 months and >= 8 migraine days per monthsee text

Pediatric approval for members 6 years and older weighing >=45 kg is also listed

Prescriber: Must be prescribed by or in consultation with a neurologist, headache specialist, or pain specialist

inv-02: Ergotamine/dihydroergotamine agents

Brekiya, Dihydroergotamine nasal spray (generic), Dihydroergotamine injection (generic), Ergomar and Migergot — covered when ALL of the following are met

Prior trials: Member has experienced inadequate response, allergies, contraindications, drug-drug interactions, or intolerable side effects with at least two triptans>=2 triptan failures

Must be prescribed by or in consultation with a neurologist, headache specialist, or pain specialist

inv-03: Elyxyb acute coverage

Elyxyb (celecoxib oral solution) — covered when ALL of the following are met

Age: Member is 18 years of age or older

Indication and prior trials: Used as acute treatment for migraine AND member has experienced inadequate response, allergies, contraindications, drug-drug interactions, or intolerable side effects with at least two NSAIDs, at least two triptans, Nurtec ODT, and Ubrelvyfailures of 2 NSAIDs + 2 triptans + Nurtec ODT + Ubrelvy

inv-04: Emgality prophylaxis and cluster headache

Emgality (galcanezumab-gnlm) — covered when ALL of the following are met

Chronic migraine prophylaxis: Member is 18 years of age or older AND diagnosis of chronic migraine with >= 15 headache days per month for at least 3 months and >= 8 migraine days per month AND has experienced inadequate response, allergies, contraindications, drug-drug interactions, or intolerable side effects with Ajovy and Aimovigsee text

Also approvable for episodic migraine (>=4 migraine days/month) after failure of Ajovy and Aimovig; and for episodic cluster headache with specified attack frequency and prior failures with verapamil and glucocorticosteroid

Prescriber: Must be prescribed by or in consultation with a neurologist, headache specialist, or pain specialist

inv-05: Nurtec ODT acute and preventive

Nurtec ODT (rimegepant) — covered when ANY of the following are met (separate acute and preventive indications)

Acute treatment: Member is 18 years of age or older AND used as acute treatment for migraine AND has experienced inadequate response, allergies, contraindications, drug-drug interactions, or intolerable side effects with at least two triptans>=2 triptan failures

Preventive treatment: Member is 18 years of age or older AND used as prophylactic treatment for episodic migraine with >= 4 migraine days per month>=4 migraine days/month

Prescriber: Must be prescribed by or in consultation with a neurologist, headache specialist, or pain specialist

inv-06: Qulipta prophylaxis

Qulipta (atogepant) — covered when ALL of the following are met

Age/Indication episodic: Member is 18 years of age or older AND diagnosis of episodic migraine with >= 4 migraine days per month>=4 migraine days/month

Age/Indication chronic: Member is 18 years of age or older AND diagnosis of chronic migraine with >= 15 headache days per month for at least 3 months and >= 8 migraine days per monthsee text

Prescriber: Must be prescribed by or in consultation with a neurologist, headache specialist, or pain specialist

inv-07: Reyvow acute coverage

Reyvow (lasmiditan) — covered when ALL of the following are met

Age: Member is 18 years of age or older

Prior trials: Used as acute treatment for migraine AND member has experienced inadequate response, allergies, contraindications, drug-drug interactions, or intolerable side effects with at least two triptans as well as with Nurtec ODT and Ubrelvyfailures of 2 triptans + Nurtec ODT + Ubrelvy

Prescriber: Must be prescribed by or in consultation with a neurologist, headache specialist, or pain specialist

inv-08: Ubrelvy acute coverage

Ubrelvy (ubrogepant) — covered when ALL of the following are met

Age: Member is 18 years of age or older

Prescriber: Must be prescribed by or in consultation with a neurologist, headache specialist, or pain specialist

inv-09: Zavzpret acute coverage

Zavzpret (zavegepant nasal spray) — covered when ANY of the following are met

Unable to tolerate oral products due to nausea/vomiting: Member is 18 years of age or older AND unable to tolerate oral products due to nausea or vomiting AND has experienced inadequate response, allergies, contraindications, drug-drug interactions, or intolerable side effects with sumatriptan nasal spray and Zomig Nasal Spray

Prior trials alternative: Member is 18 years of age or older AND has experienced inadequate response, allergies, contraindications, drug-drug interactions, or intolerable side effects with at least two triptans as well as with Nurtec ODT and Ubrelvyfailures of 2 triptans + Nurtec ODT + Ubrelvy

Prescriber: Must be prescribed by or in consultation with a neurologist, headache specialist, or pain specialist

Exceptions to the conditions of coverage in this policy are not processed outside the prior authorization workflow. All requests for exceptions must be submitted and reviewed through the standard prior authorization process administered by OptumRx.

This policy does not provide a single, standalone list of not medically necessary (NMN) conditions. Instead, coverage determinations are made using agent-specific clinical criteria described for each medication; if a patient’s clinical circumstances do not meet an individual agent’s listed criteria, that agent would not be approvable under this policy.

Clinical Thresholds and Definitions for Eligibility

Episodic migraine threshold

Episodic migraine threshold>= 4 migraine days per month

Age requirement (typical)Adult: 18 years or older (pediatric approval noted for some agents)

Use caseThreshold applies for prophylactic (preventative) treatment eligibility

Chronic migraine threshold

Chronic migraine threshold>= 15 headache days per month for at least 3 months AND >= 8 migraine days per month

Age requirementAdult: 18 years or older

Applicability

Prior Authorization, Step Therapy, and Submission Instructions

Prior Authorization

Prior authorization required

Prior authorization is required for both preferred and non-preferred antimigraine agents; length of authorization varies.

Step Therapy

Document required prior trials (step therapy)

Many agents require documented prior trials showing inadequate response, allergy, contraindication, drug–drug interaction, or intolerance to specified alternatives (commonly at least two triptans for acute agents and specified alternatives for other agents).

Acute agents often require >=2 triptan failures (e.g., Ubrelvy, Nurtec ODT acute, Brekiya/DHE/Ergotamine).
Some agents require trials of additional agents (e.g., Elyxyb requires failures of 2 NSAIDs, 2 triptans, Nurtec ODT, and Ubrelvy).
Reyvow and Zavzpret may require failures of Nurtec ODT and Ubrelvy in addition to triptans.

Policy Scope and Context

This policy defines the clinical eligibility criteria for both prophylactic and acute antimigraine medications. Criteria are provided per agent and distinguish common clinical thresholds (for example, episodic migraine: ≥4 migraine days/month; chronic migraine: ≥15 headache days/month for ≥3 months with ≥8 migraine days/month), required prior therapy trials, and prescriber specialty requirements where applicable.

Key Clinical Definitions

Episodic migraine definition

DefinitionMigraine headaches occurring at least 4 migraine days per month

Clinical useDefines eligibility for episodic migraine prophylactic therapies

Common agents referencing thisAimovig, Qulipta, Nurtec ODT (preventive indication), Emgality (episodic after prior failures)

Chronic migraine definition

DefinitionAt least 15 headache days per month for >= 3 months with >= 8 migraine days per month

Clinical implicationDefines chronic migraine for prophylactic therapy eligibility and step-therapy requirements

Referenced agents

Policy Revision Timeline

document_publishedLatest

Georgia Medicaid Fee-for-Service antimigraine agents prior authorization summary published with clinical coverage criteria, prior authorization requirement, and exceptions process (OptumRx PA contact).