CurrentmhnPolicy CP.PHAR.566

QULIPTA (PDF)

Defines medical necessity criteria, prior authorization requirements, dosing limits, continuation criteria, concurrent therapy restrictions, exclusions, and administrative references for Qulipta (atogepant) for migraine prevention across Commercial, HIM, and Medicaid lines of business.

Policy Summary

Payermhn

PolicyQULIPTA (PDF)

Policy CodePolicy CP.PHAR.566

Change TypeMultiple updates (added contraindicated agent, IL step therapy bypass, dosing/indication, approval duration)

Effective DateMar 1, 2022

Next Review Date

Key ActionProvider must submit documentation supporting that the member meets all approval criteria; prior authorization may be required for alternative CGRP therapies.

SourceLink

POLICY UPDATE CHANGES

Added Zavzpret to list of CGRP inhibitors that should not be prescribed concurrently with Qulipta.

Added step therapy bypass for IL HIM per IL HB 5395 effective 2026-01-01.

Revised approval duration to 12 months.

Incorporated expanded indication for preventive treatment of chronic migraine.

12Approval duration

≥18Minimum age (yrs)

2Required prior oral therapies

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