CurrentNeighborhood Health Plan of Rhode IslandPolicy 3481-E

Step therapy and quantity limits for oral and nasal CGRP receptor antagonists (migraine)

Step therapy, quantity limits, and prior authorization rules for oral and nasal calcitonin gene-related peptide (CGRP) receptor antagonists for migraine in adults administered under CVS Caremark benefits (applies to Neighborhood Health Plan of Rhode Island).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyStep therapy and quantity limits for oral and nasal CGRP receptor antagonists (migraine)

Policy CodePolicy 3481-E

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization when step therapy criteria or initial quantity limits are not met and provide documentation of prior trials or contraindications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4drugs listed (Nurtec ODT, Qulipta, Ubrelvy, Zavzpret)

16 / 48Nurtec ODT monthly / 3-month

30 / 90Qulipta monthly / 3-month

6 / 24Zavzpret 3-week / 3-month

12 monthsApproval duration (acute)

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Coverage Criteria for Oral and Nasal CGRP Receptor Antagonists

The oral CGRP receptor antagonists Ubrelvy (ubrogepant) and Zavzpret (zavegepant) are FDA‑approved for the acute treatment of migraine in adults. They have an explicit limitation of use: neither Ubrelvy nor Zavzpret is indicated for preventive treatment of migraine.

Coding and Trial Supply Thresholds

Prior trial supply thresholds

Triptan trial requirementTwo triptan 5-HT1 receptor agonists with at least a 30-day supply each within the past 180 days

Preventive agent trial requirementAt least a 56-day supply of a listed preventive agent (eg, divalproex sodium, topiramate, valproate sodium, valproic acid, metoprolol, propranolol, timolol, atenolol, nadolol, candesartan, amitriptyline, or venlafaxine) within the past 730 days

Applies to initial step therapy determinationsThese supply thresholds are used to determine whether initial step therapy criteria are met for acute and preventive agents; failure to meet them will trigger a PA requirement

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required when step therapy or quantity limit criteria are not met. If the patient does not meet initial step therapy criteria for the requested drug, the claim will reject with a message that a prior authorization (PA) is required and the request must be submitted to the PA unit for review. If the patient meets initial step therapy criteria but is requesting more than the initial quantity limit, the claim will reject with a message that a PA is required and the request must be submitted to the PA unit for review.

Claims for members who have not met required step therapy will reject and require PA submission to the PA unit.
Claims requesting quantities exceeding initial limits will reject and require PA submission to the PA unit.
Limits do not accumulate together; member may receive the maximum limit for each drug and strength.
Dispensing pharmacies may fill per manufacturer package size up to quantity limits; day supply may be less than indicated.

Step Therapy

Step Therapy Requirements and Allowable Substitutions

Background on CGRP Receptor Antagonists

Calcitonin gene‑related peptide (CGRP) receptor antagonists are available in oral and nasal formulations and are indicated for either acute or preventive treatment of migraine depending on the specific agent.

Specifically, Nurtec ODT (rimegepant) is approved for both the acute treatment of migraine and for preventive treatment of episodic migraine; Qulipta (atogepant) is approved for preventive treatment of migraine in adults; and Ubrelvy (ubrogepant) and Zavzpret (zavegepant) are approved for the acute treatment of migraine only.

Indication Summaries and Agent Definitions

Indication summaries

Nurtec ODTIndicated for both acute treatment of migraine and preventive treatment of episodic migraine in adults

QuliptaIndicated for the preventive treatment of migraine in adults

UbrelvyIndicated for the acute treatment of migraine in adults; not indicated for prevention

ZavzpretIndicated for the acute treatment of migraine in adults; not indicated for prevention

Initial step therapy requirements vary by product. For Ubrelvy and Zavzpret, the member must have filled at least a 30-day supply of two triptan (5-HT1 receptor) agonists within the past 180 days. For Nurtec ODT, the member must have either filled at least a 30-day supply of two triptan (5-HT1 receptor) agonists within the past 180 days OR at least a 56-day supply of specified preventive agents (divalproex sodium, topiramate, valproate sodium, valproic acid, metoprolol, propranolol, timolol, atenolol, nadolol, candesartan, amitriptyline, or venlafaxine) within the past 730 days. For Qulipta, the member must have filled at least a 56-day supply of one of the specified preventive agents within the past 730 days. Include prescription (Rx) and over-the-counter (OTC) products unless otherwise stated.

Documentation Required

Required Clinical Documentation

Documentation required for prior authorization evaluation: provide the drug requested, the indication (acute treatment of migraine or preventive treatment of episodic/migraine), prior treatments and duration (including dates and whether trials were inadequate or intolerant), and any contraindications to required step agents. For continuation of therapy, document treatment duration and clinical response (e.g., reduction in migraine days per month from baseline when applicable).

Requested drug name and formulation (e.g., Nurtec ODT, Ubrelvy, Zavzpret, Qulipta).
Indication: acute treatment vs preventive treatment (episodic or chronic) and patient age (adult).
Prior treatment history: names of agents tried (including triptans and listed preventive agents), duration of trials (days supply and dates), and reason for discontinuation (inadequate response or intolerance).
Any contraindications to triptan 5-HT1 receptor agonists or other required step agents.
For continuation requests: documentation of at least 3 months of therapy when required and evidence of clinical benefit (e.g., reduction in migraine days per month from baseline).