CurrentNeighborhood Health Plan of Rhode IslandPolicy 3481-E

Oral and nasal CGRP receptor antagonists (Nurtec ODT, Qulipta, Ubrelvy, Zavzpret) – step therapy, quantity limits, and prior authorization

Defines step therapy, quantity limits, and prior authorization criteria for oral and nasal CGRP receptor antagonist migraine treatments (Nurtec ODT, Qulipta, Ubrelvy, Zavzpret) for adults under the payer's pharmacy benefit.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOral and nasal CGRP receptor antagonists (Nurtec ODT, Qulipta, Ubrelvy, Zavzpret) – step therapy, quantity limits, and prior authorization

Policy CodePolicy 3481-E

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization when step therapy criteria are unmet or requested quantity exceeds initial limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4drugs covered

2approval durations

16/48Nurtec ODT limit (mo/3mo)

30/90Qulipta limit (mo/3mo)

6/24Zavzpret limit (mo/3mo)

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Coverage Criteria for Oral and Intranasal CGRP Receptor Antagonists

Acute treatment (Nurtec ODT, Ubrelvy, Zavzpret)

Authorization may be granted when the requested drug is being prescribed for the acute treatment of migraine in an adult patient when ALL of the following criteria are met:

Acute treatment - overall: Request is for Nurtec ODT, Ubrelvy, or Zavzpret.

Acute treatment - patient-level requirement

Triptan trial or contraindication: Either (a) inadequate treatment response or intolerance to TWO triptan 5-HT1 receptor agonists OR (b) contraindication to triptans.two triptan trials
Refer to step therapy requirements for acceptable trial documentation and timing.

Documentation: Provider must document prior trials/intolerances to two triptans or a documented contraindication to triptans.

Claims will reject and require prior authorization if initial step therapy criteria are not met.

Preventive treatment - Nurtec ODT (episodic)

Authorization may be granted when the requested drug is being prescribed for the preventive treatment of episodic migraine in an adult patient when ALL of the following criteria are met:

Nurtec ODT preventive - initial: Request is for Nurtec ODT AND patient has NOT received at least 3 months of treatment with the requested drug.treatment duration: <3 months

Initial authorization duration 3 months.

Nurtec ODT preventive - continuation: Request is for Nurtec ODT AND patient has received at least 3 months of treatment with the requested drug AND the patient had a reduction in migraine days per month from baseline.evidence of response after ≥3 months

Continuation authorization duration 12 months.

Preventive treatment - Qulipta

Authorization may be granted when the requested drug is being prescribed for the preventive treatment of migraine in an adult patient when ALL of the following criteria are met:

Qulipta preventive - initial: Request is for Qulipta AND patient has NOT received at least 3 months of treatment with the requested drug.treatment duration: <3 months

Initial authorization duration 3 months.

Qulipta preventive - continuation: Request is for Qulipta AND patient has received at least 3 months of treatment with the requested drug AND the patient had a reduction in migraine days per month from baseline.evidence of response after ≥3 months

Continuation authorization duration 12 months.

Ubrelvy and Zavzpret are oral/nasal CGRP receptor antagonists approved for the acute treatment of migraine in adults but have explicit limitations of use: both agents are not indicated for preventive treatment of migraine. These limitations mean requests for these drugs for migraine prevention do not meet the agent-specific indications in this policy and should follow the coverage criteria for acute use or be considered non‑covered for preventive indications.

Covered Drugs and Quantity Limits

Covered drugs (brand - generic)NDC | drug namesCovered

Nurtec ODT	rimegepant
Qulipta	atogepant
Ubrelvy	ubrogepant
Zavzpret	zavegepant

mixed

No codes listed

Quantity limits (drug-specific)other

Nurtec ODT	1 Month Limit = 16 orally disintegrating tablets / 25 days; 3 Month Limit = 48 orally disintegrating tablets / 75 days
Qulipta	1 Month Limit = 30 tablets / 25 days; 3 Month Limit = 90 tablets / 75 days
Ubrelvy	1 Month Limit = 16 tablets / 25 days; 3 Month Limit = 48 tablets / 75 days
Zavzpret	1 Month Limit = 6 nasal spray units / 18 days (3-week fill); 3 Month Limit = 24 nasal spray units / 75 days

mixed

No codes listed

Quantity limits — drug-specific

Nurtec ODT (rimegepant) quantity limit16 orally disintegrating tablets per month (25 days); 48 tablets per 3 months (75 days)

Qulipta (atogepant) quantity limit30 tablets per month (25 days); 90 tablets per 3 months (75 days)

Ubrelvy (ubrogepant) quantity limit16 tablets per month (25 days); 48 tablets per 3 months (75 days)

Zavzpret (zavegepant) quantity limit6 nasal spray units per month-equivalent (18 days / 3-week fill); 24 nasal spray units per 3 months (75 days)

Provider Requirements, Prior Authorization, and Step Therapy

Prior Authorization

Prior Authorization Required

Prior authorization is required when initial step therapy criteria are not met or when the requested quantity exceeds the initial quantity limit. Claims will reject with a message indicating that a prior authorization (PA) is required in these situations; the PA criteria will then be applied to requests submitted for evaluation to the PA unit.

Applies to initial step therapy for Ubrelvy, Zavzpret, Nurtec ODT, and Qulipta
If patient does not meet the initial step therapy criteria, claim will reject and PA is required
If patient meets step therapy but is requesting more than the initial quantity limit, claim will reject and PA is required

Step Therapy

Initial Step Therapy Requirements

Initial step therapy requirements (examples): For Ubrelvy and Zavzpret, patient must have filled at least a 30-day supply of two triptan 5-HT1 receptor agonists within the past 180 days. For Nurtec ODT, patient must have filled either 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, patient must have filled at least a 56-day supply of the specified preventive agents within the past 730 days. Include both prescription (Rx) and over-the-counter (OTC) products unless otherwise stated.

Agent Indications and Definitions

Agent indications

Nurtec ODT — approved indicationsAcute treatment of migraine and preventive treatment of episodic migraine in adults

Qulipta — approved indicationPreventive treatment of migraine in adults

Ubrelvy — approved indicationAcute treatment of migraine in adults (not indicated for prevention)

Zavzpret — approved indicationAcute treatment of migraine in adults (not indicated for prevention)

Background on CGRP Receptor Antagonists

CGRP receptor antagonists in oral and intranasal formulations have differing FDA‑approved roles depending on the product. Nurtec ODT has both acute and preventive indications (episodic migraine), Qulipta is indicated for preventive treatment of migraine in adults, and Ubrelvy and Zavzpret are indicated for the acute treatment of migraine only. This policy aligns step therapy, quantity limits, and prior authorization requirements with those agent‑specific indications and the labeled limitations of use.