CurrentNeighborhood Health Plan of Rhode IslandPolicy 3481-E

Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists Oral: Ubrelvy, Qulipta

Defines step-therapy, quantity limits, prior authorization criteria, and duration of approval for Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), and Zavzpret (zavegepant) for acute and preventive treatment of migraine in adults.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCalcitonin Gene-Related Peptide (CGRP) Receptor Antagonists Oral: Ubrelvy, Qulipta

Policy CodePolicy 3481-E

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf step therapy criteria are not met or quantity limits are exceeded, submit a prior authorization; PA criteria will be applied to requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

4Drugs referenced

2Indications covered (acute, preventive)

3Duration of Approval categories

Coverage Summary

Coverage stance: covered_with_criteria. This policy (Policy Number: 3481-E; Subject: Oral and nasal CGRP receptor antagonists (Nurtec ODT, Qulipta, Ubrelvy, Zavzpret)) defines step therapy, quantity limits, prior authorization criteria, and durations of approval for rimegepant (Nurtec ODT), atogepant (Qulipta), ubrogepant (Ubrelvy), and zavegepant (Zavzpret).

Products/indications covered: Nurtec ODT (rimegepant) — acute and preventive indications; Qulipta (atogepant) — preventive indication; Ubrelvy (ubrogepant) — acute indication; Zavzpret (zavegepant) — acute indication. Quantity limits and duration of approval differ by product.

Claims will pay under the prescription benefit when the applicable step therapy criteria are met for the requested product; if step criteria are not met (or the requested quantity exceeds the initial limit) the claim will reject and a prior authorization (PA) is required and PA criteria will be applied.

Key limits & durations

Triptan trial requirementAt least a 30-day supply of two triptan 5-HT1 receptor agonists within the past 180 days

Alternate preventive agent trial (Nurtec ODT or Qulipta initial)At least a 56-day supply of listed preventive agents within the past 730 days

Nurtec ODT limits16 ODT tablets per 25 days (month); 48 tablets per 75 days (3 months)

Qulipta limits30 tablets per 25 days (month); 90 tablets per 75 days (3 months)

Ubrelvy limits16 tablets per 25 days (month); 48 tablets per 75 days (3 months)

Zavzpret limits6 nasal spray units per 18 days (≈3-week); 24 units per 75 days (3 months)

Duration of Approval (DOA)Acute: 12 months (Nurtec ODT, Ubrelvy, Zavzpret); Preventive initial: 3 months (Nurtec ODT, Qulipta); Preventive continuation: 12 months (Nurtec ODT, Qulipta)

Initial Therapy / Step Therapy Criteria

Step Therapy

If step criteria not met, PA required

If the patient does not meet the initial step therapy criteria, the claim will reject and a prior authorization (PA) is required. The PA criteria will be applied to requests submitted to the PA unit. (Applies to initial step therapy for Ubrelvy and Zavzpret; also for Nurtec ODT with its alternate step options.)

Acute Treatment — Coverage Criteria

Prior Authorization

Prior authorization required if step criteria not met or quantity exceeds limit

Prior authorization is required if the patient does not meet initial step therapy criteria or is requesting more than the initial quantity limit; the claim will reject with a message indicating PA is required and PA criteria will be applied to requests submitted to the PA unit. This applies to acute products Nurtec ODT, Ubrelvy, and Zavzpret.

Affected acute products: Nurtec ODT, Ubrelvy, Zavzpret

Billing Rule

Quantity limits enforced with specific day-supply mapping

Quantity limits are enforced with specific day-supply mapping: 18 days for a 21-day fill period, 25 days for a 30-day fill period, and 75 days for a 90-day fill period to allow refill processing. Pharmacies may fill up to manufacturer package sizes at their discretion within these limits.

Continuation Therapy Criteria

Continuation of Therapy - Acute

Preventive initial therapy DOA threshold: Initial preventive therapy duration of approval is 3 months for Nurtec ODT and Qulipta3 months

This threshold applies to initial preventive therapy and is used to determine initial approval duration

ref": "b3_1

title": "Initial Preventive Therapy Thresholds"

Documentation Required

Continuation requires documentation of benefit

For continuation of preventive therapy, the provider must document at least 3 months of prior treatment with the requested drug and a reduction in migraine days per month from baseline.

Applicable Codes / Products Referenced

Drugs referenced (brand and generic, all dosage forms/strengths)mixedCovered

Nurtec ODT	rimegepant orally disintegrating tablet — acute and preventive indications per policy
Qulipta	atogepant tablets — preventive treatment of migraine
Ubrelvy	ubrogepant tablets — acute treatment of migraine
Zavzpret	zavegepant nasal spray — acute treatment of migraine

Provider Actions & Billing Rules

Prior Authorization

If patient does not meet initial step therapy criteria or is requesting more than initial quantity limit, claim will reject and PA required; PA criteria applied by PA unit

If the patient does not meet initial step therapy criteria or is requesting more than the initial quantity limit, the claim will reject and a prior authorization is required; PA criteria will be applied by the PA unit upon submission.

Billing Rule

Quantity limits enforced with day-supply mapping and package-size discretion

Quantity limits map to fill durations as follows: 18 days for a 21-day fill, 25 days for a 30-day fill, and 75 days for a 90-day fill. Pharmacies may dispense up to package sizes at their discretion within these limits.

18 days = 21-day fill mapping
25 days = 30-day fill mapping
75 days = 90-day fill mapping
Dispensing up to package sizes is at pharmacy discretion

Documentation Required

Continuation requires documentation of benefit: at least 3 months prior treatment and reduction in migraine days

For preventive therapy continuation (Nurtec ODT, Qulipta), providers must document at least 3 months of treatment with the requested drug and that the patient experienced a reduction in migraine days per month from baseline to qualify for continuation.

Operational note for claims: Claims will pay under the prescription benefit if the member has met the applicable step therapy requirements specified for the requested drug. If step criteria are not met (or the request exceeds initial quantity limits), the claim will reject with a message that a prior authorization (PA) is required; submit the PA to the PA unit and PA criteria will be applied.

Background

Background: The class includes both brand and generic formulations of CGRP receptor antagonists across oral and nasal dosage forms. Nurtec ODT (rimegepant) has both an acute and a preventive FDA indication; Qulipta (atogepant) is indicated for preventive treatment only; Ubrelvy (ubrogepant) and Zavzpret (zavegepant) are indicated for acute treatment only. Step therapy requirements and product-specific quantity limits apply per the policy and are enforced at claim adjudication; if criteria are not met, PA is required.

Definition — Triptan 5-HT1 receptor agonists: A class of acute migraine medications used as the required initial therapeutic trial for certain acute CGRP antagonist approvals; the policy requires trials or contraindications to two triptan agents (or specified alternative trials for preventive indications) as part of step therapy/prior authorization criteria.