Calcitonin Gene-Related Peptides (CGRP) Inhibitors Prior Authorization Criteria
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Prior authorization requirements and clinical criteria for calcitonin gene‑related peptide (CGRP) inhibitors used for prevention and acute treatment of migraine and for episodic cluster headache for Mississippi Division of Medicaid members.
No material clinical or coverage changes in this revision.
Coverage Criteria for CGRP Inhibitors
Acute migraine — Preferred agents (Nurtec ODT, Ubrelvy) / Initial authorization 6 months
Covered for acute migraine when ALL of the following are met for preferred agents (Nurtec ODT or Ubrelvy):
Acute migraine — Non-preferred (Zavzpret) / Initial authorization 6 months
Covered for acute migraine when ALL of the following are met for non‑preferred agent Zavzpret:
Prevention — Episodic and Chronic Migraine
Covered for prevention when ALL of the following are met:
Episodic cluster headache — Emgality 300 mg
Covered for episodic cluster headache with Emgality 300 mg when ALL of the following are met:
The following situations are explicit exclusions for prior authorization of any CGRP inhibitor: use of the requested CGRP agent within 12 weeks of the last onabotulinumtoxinA (Botox) administration is not allowed and will result in denial; therapy will not be authorized for patients who are currently pregnant or nursing; and requests for members whose diagnosis is medication overuse headache or tension‑type headache are excluded.
Requests for CGRP inhibitors submitted for the indication of medication overuse headache or for tension‑type headache are considered not medically appropriate and will be denied.
Products, Codes, and Definitions
| Aimovig | erenumab-aooe — prevention (70mg, 140mg) |
| Ajovy | fremanezumab-vfrm — prevention (225mg monthly; 675mg quarterly) |
| Emgality | galcanezumab-gnlm — prevention; Emgality 300mg indicated for episodic cluster headache |
| Nurtec ODT | rimegepant — acute and prevention (75mg) |
| Qulipta | atogepant — prevention (10/30/60mg) |
| Ubrelvy | ubrogepant — acute (50/100mg) |
| Zavzpret | zavegepant — acute (nasal spray 10mg) |
| amitriptyline, nortriptyline, duloxetine, venlafaxine | Antidepressants listed as non-CGRP preventive options |
| atenolol, metoprolol, nadolol, propranolol, timolol | Beta-blockers listed as non-CGRP preventive options |
| divalproex/topiramate | Anticonvulsants listed as non-CGRP preventive options |
| candesartan | Angiotensin II receptor blocker listed as non-CGRP preventive option |
| onabotulinumtoxinA (Botox) | Chronic migraine only preventive option |
Prior Authorization, Step Therapy, and Submission Requirements
Prior authorization required; initial and reauthorization durations
Prior authorization is required for all listed CGRP inhibitors. Initial authorization durations vary by indication: acute migraine requests are authorized for 6 months; prevention requests are authorized for 12 weeks initially; episodic cluster headache (Emgality 300 mg) initial authorization is 12 weeks. Reauthorization for prevention and cluster indications is typically 12 months and requires documentation of positive response and functional improvement.
- Acute treatment initial authorization: 6 months [[chunk 4]]
- Prevention initial authorization: 12 weeks; reauthorization: 12 months with documentation of response [[chunk 13],[chunk 14]]
- Episodic cluster headache (Emgality) initial authorization: 12 weeks; reauthorization up to 12 months per cluster period with documented response [[chunk 17],[chunk 19]]
- PA required for all listed CGRP products; submit Universal PA Form and supporting documentation indicating the requested indication [[chunk 1]]
Step therapy: required prior trials and failures
Step therapy requires documented trials and failures of preferred agents and non‑CGRP preventive classes before non‑preferred or prevention CGRP agents are approved. For non‑preferred acute agent Zavzpret, provider must document trial and failure of Nurtec ODT AND Ubrelvy in the past 6 months. For prevention, at least one 8‑week consecutive trial at optimal dose of therapies from two different non‑CGRP preventive classes (or Botox for chronic migraine when applicable) is required, with at least one trial within the past 12 months.
- Non‑preferred acute (Zavzpret): trial and failure of Nurtec ODT AND Ubrelvy within past 6 months [[chunk 6]]
- Prevention: documented failure of a consecutive 8‑week trial at optimal dose of at least ONE therapy from any TWO different non‑CGRP preventive classes (or onabotulinumtoxinA for chronic migraine) [[chunk 13]]
- At least one preventive trial must have occurred within the past 12 months; provide paid pharmacy claims or documentation of intolerance/contraindication [[chunk 13]]
- Non‑preferred agents require trying and failing two preferred agents where specified (must document dates and claims) [[chunk 10]]
Submission requirements and required documentation
Submit the Universal PA Form with supporting clinical documentation and clearly denote the indication requested (acute treatment, episodic or chronic prevention, or episodic cluster headache). For episodic cluster headache or medications administered in the prescriber's office, include diagnosis, chart notes upon request, previous therapies tried/failed, and the documented date of first administered dose if applicable.
- Universal PA Form plus supporting clinical documentation; indicate the requested indication on the form [[chunk 1]]
- For episodic cluster: supply diagnosis, chart notes if requested, previous therapies tried/failed, and date of first administered dose in prescriber's office if applicable [[chunk 16],[chunk 17]]
Denial conditions and high‑risk scenarios
PA requests will be denied if the member received Botox within the prior 12 weeks, if the member is currently pregnant or nursing, or if the diagnosis is medication overuse headache or tension‑type headache.
- Do not request CGRP therapy within 12 weeks of last onabotulinumtoxinA (Botox) administration — such requests will be denied [[chunk 2]]
- Requests for members who are currently pregnant or nursing will be denied [[chunk 2]]
- Requests for medication overuse headache or tension‑type headache will be denied as not appropriate indications [[chunk 2]]
Clinical Background
Calcitonin gene‑related peptide (CGRP) inhibitors encompassed by this policy are targeted therapies used in migraine and cluster headache management. This policy’s denial criteria note clinical situations where CGRP therapy is not appropriate, including recent Botox within 12 weeks, pregnancy or nursing, and primary headache diagnoses of medication overuse headache or tension‑type headache.
Key Definitions and Contraindications
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