Criteria for Prior Authorization — Migraine Acute Treatment Agents
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Defines prior authorization requirements for specific acute migraine medications (e.g., lasmiditan, rimegepant, ubrogepant, zavegepant, celecoxib) including initial and renewal criteria, dosing limits, and required prior therapies. Affects prescribers and pharmacies requesting PA from Kansas Department of Health and Environment.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy
Covered when ALL of the following are met for initial prior authorization
Initial PA requirements
- Regulatory and dosing: Agent is approved for the indication and age and dosing does not exceed Table 1 limitsSee Table 1
- Red flag screen: No unresolved or unaddressed red flag headache symptoms (see Table 3)
- Preferred drug/PDL: Preferred PDL drug for the PA indication is required unless non-preferred PDL PA criteria are met
- Diagnosis of migraine meeting ICHD-3 criteria
- Frequency: Patient has <4 migraines per month; if ≥4 per month, patient must be actively on prophylactic treatment<4/month or on prophylaxis
- Pain intensity: Prescriber determines pain intensity of migraine attacks is moderate or severe
- Prior triptan trials: Inadequate response after trial (at least 2 weeks) of 2 different triptans at maximum tolerated dose OR documented intolerance/contraindication to all triptans listed in Table 22 triptans
Prescriber must document medication names, trial dates, and outcomes (inadequate response, intolerance, or contraindication)
Continuation/Renewal
Renewal criteria — must meet ALL of the following
Renewal requirements
- Dose limit: Dose does not exceed Table 1 limitsSee Table 1
- Clinical improvement: Provider attests that the patient has experienced an improvement in migraine symptoms
- Frequency or prophylaxis: Migraines occurring <4 times per month OR patient is actively on prophylactic therapy; for patients who continue to have ≥4 migraines per month, prescriber must document optimization of prophylactic treatment since last approval<4/month or on prophylaxis
- No added acute agents: Patient has not required the addition of any other acute treatment agent used for migraine since last approval
Patients presenting with any unresolved or unaddressed red flag headache symptoms are excluded from approval until those findings are evaluated and addressed. Examples of red flag symptoms include, but are not limited to, new onset after age 50, progressively increasing severity, persistent headache after Valsalva or exertion, neurologic signs or seizures, systemic symptoms such as fever or weight loss, and a 'thunderclap' headache (maximum severity at onset).
Prescribers must resolve or document appropriate evaluation of these concerning features (see Table 3) prior to initiation of the acute migraine agents covered by this policy.
Approval requires use of the preferred PDL drug for the PA indication when one is available. Use of a non-preferred PDL drug without meeting the plan’s non-preferred PDL prior authorization criteria is considered not medically necessary.
Additionally, requests must meet the policy’s dosing, indication, and age requirements listed in Table 1. Failure to meet those dosing/indication/age limits may result in the request being denied as not medically necessary.
Drug Listings and Coding
| lasmiditan (Reyvow) | Acute treatment agent; tablets 50 mg, 100 mg; recommended dose 50, 100, or 200 mg once in 24 hours; no more than one dose per 24 hours. |
| rimegepant (Nurtec ODT) | CGRP receptor antagonist; acute treatment agent (ODT formulation). |
| ubrogepant (Ubrelvy) | Acute treatment agent. |
| zavegepant (Zavzpret) | Intranasal acute treatment agent; 10 mg (one spray) intranasally per 24 hours. |
| celecoxib (Elyxyb) | COX-2 selective NSAID oral solution for acute migraine; 120 mg orally once in 24 hours. |
| almotriptan (Axert) | Triptan listed in Table 2 |
| sumatriptan/naproxen (Treximet) | Combination triptan/NSAID listed in Table 2 |
| eletriptan (Relpax) | Triptan listed in Table 2 |
| frovatriptan (Frova) | Triptan listed in Table 2 |
| naratriptan (Amerge) | Triptan listed in Table 2 |
| rizatriptan (Maxalt) | Triptan listed in Table 2 |
| sumatriptan (Imitrex) | Triptan listed in Table 2 |
| zolmitriptan (Zomig) | Triptan listed in Table 2 |
Provider Actions and Documentation Requirements
Prior authorization required for listed acute migraine agents
Prior authorization is required for all current and future dose forms of the listed acute migraine agents; medication-specific criteria including indication, age, and dose must meet the limits in Table 1.
Triptan step requirement: trial of 2 triptans
Patient must have an inadequate response after a trial (at least 2 weeks) of two different triptans at maximum tolerated dose, or have a documented intolerance or contraindication to all triptans listed in Table 2.
- Trials must be at maximum tolerated dose and at least 2 weeks in duration.
Document prior medication trials (names, dates, outcomes)
Prescriber must provide details of all prior medication trials for acute migraine therapies, including medication name(s), trial date(s), and outcome(s) (e.g., inadequate response, intolerance, or contraindication).
Triggers for denial if criteria or documentation not met
Requests may be denied if the requestor fails to meet any initial or renewal criteria—examples include exceeding Table 1 dosing limits, unresolved or unaddressed red flag headache symptoms, insufficient documentation of prior triptan trials, migraine frequency not meeting criteria, or addition of another acute migraine agent during the approval period.
- Dose exceeds limits in Table 1 (renewal and initial limits apply).
- Unresolved/unaddressed red flag headache symptoms per Table 3.
- Insufficient documentation of prior triptan trials (names, dates, outcomes).
- Patient does not meet monthly frequency requirement (<4/month or actively on prophylaxis).
- Patient required addition of another acute migraine agent since last approval (renewal).
Background
These criteria apply to the acute treatment of migraine and require that the patient have a diagnosis of migraine meeting the International Classification of Headache Disorders, 3rd edition (ICH D-3) diagnostic criteria.
The policy references FDA‑approved agents and dosing limits and is intended to align with professional society guidance for acute migraine management; it also incorporates requirements for prior triptan trials, frequency thresholds, and documentation to support medical necessity.
Definitions
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