CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Oral and Nasal CGRP Receptor Antagonists (Nurtec ODT, Qulipta, Ubrelvy, Zavzpret) step therapy and quantity limits

Step therapy and post-step prior authorization policy governing coverage, step requirements, quantity limits, and continuation criteria for oral and nasal CGRP receptor antagonists (rimegepant, atogepant, ubrogepant, zavegepant) for adult migraine treatment under a CVS Caremark-administered prescription benefit.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOral and Nasal CGRP Receptor Antagonists (Nurtec ODT, Qulipta, Ubrelvy, Zavzpret) step therapy and quantity limits

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf the patient does not meet initial step therapy criteria or requests more than the initial quantity limit, submit a prior authorization (PA) to the PA unit for evaluation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — policy remains as previously established.

4Drugs covered (brand names listed)

YesQuantity limits enforced

StepStep therapy required (PA fallback)

Coverage Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

This policy covers oral and nasal CGRP receptor antagonists — Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), and Zavzpret (zavegepant) — under a CVS Caremark-administered step therapy and quantity-limit program. Coverage is conditional: drugs are covered with criteria when initial step-therapy requirements are met. If step criteria are not met or the requested quantity exceeds the initial quantity limits, a prior authorization (PA) is required and the claim will reject until PA review.

Key Thresholds

Triptan trialContraindication to triptans OR inadequate response/intolerance to two triptan 5-HT1 receptor agonists

Qulipta prior preventive therapyInadequate response to an 8-week trial of AEDs OR beta-blockers OR antidepressants (specific agents listed: divalproex sodium, topiramate, valproate sodium; metoprolol, propranolol, timolol, atenolol, nadolol; amitriptyline, venlafaxine) OR documented intolerance/contraindication

Qulipta responseAt least 3 months of treatment with the requested drug and a reduction in migraine days per month from baseline

Continuation / Response Criteria

Qulipta continuation/response requirement

Qulipta continuation requirement

3-month treatment and response: Patient received at least 3 months of treatment with the requested drug and had a reduction in migraine days per month from baseline3 months
Documented reduction in migraine days per month from baseline required for continuation

Applicable Drugs / Codes

Drugs covered under step therapy / subject to quantity limitsNDC|mixedCovered

Nurtec ODT	rimegepant — acute treatment of migraine; preventive treatment of episodic migraine (adult)
Qulipta	atogepant — preventive treatment of migraine (adult)
Ubrelvy	ubrogepant — acute treatment of migraine (adult); not indicated for prevention
Zavzpret	zavegepant nasal spray — acute treatment of migraine (adult); not indicated for prevention

Provider Actions & Requirements

Prior Authorization

Prior authorization required when step criteria not met or quantity exceeded

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 (PA) must be submitted for evaluation to the PA unit.

Note: Claim will reject and a PA must be submitted if step criteria not met or quantity exceeded.

Documentation Required

Document triptan trials or contraindication

Providers must document either a contraindication to triptan therapy or an inadequate response or intolerance to two triptan 5-HT1 receptor agonists for acute-indication requests.

Document a contraindication to triptan therapy OR inadequate response/intolerance to two triptan 5-HT1 receptor agonists.

Documentation Required

Document prior preventive therapy or intolerance for Qulipta

For Qulipta (preventive), providers must document an inadequate response to an 8-week trial of one or more of the listed agents (antieleptic drugs, beta-blockers, or antidepressants), or document intolerance or a contraindication to those agents; additionally, for continuation, document at least 3 months of treatment with the requested drug and a reduction in migraine days per month from baseline.

Document an inadequate response to an 8-week trial of any of: A) AEDs (e.g., divalproex sodium, topiramate, valproate sodium), B) beta-blockers (e.g., metoprolol, propranolol, timolol, atenolol, nadolol), or C) antidepressants (e.g., amitriptyline, venlafaxine) OR document intolerance/contraindication to these agents.
For continuation: document at least 3 months of treatment with the requested drug and reduction in migraine days per month from baseline.

Billing Rule

Quantity limit enforcement

Claims will reject if the requested quantity exceeds the established limits. Pharmacies may dispense per manufacturer package sizes up to these quantity limits; fill-period mapping is used to allow refill processing.

Fill-period mapping: 18 days for a 21-day fill period, 25 days for a 30-day fill period, 75 days for a 90-day fill period.
Quantity limits examples: Nurtec ODT and Ubrelvy — 16 per month (48 per 3 months); Qulipta — 30 per month (90 per 3 months); Zavzpret — 6 units per 3 weeks (24 per 3 months).
Claims will reject if quantity exceeds limits; pharmacy may dispense per package sizes up to the limits.

Background & Clinical Evidence

This CVS Caremark-administered policy implements step therapy and quantity limits for oral and nasal CGRP receptor antagonists used to treat acute and preventive migraine in adults. It references FDA-approved indications for each agent (e.g., Nurtec ODT for acute and preventive use; Ubrelvy and Zavzpret for acute use only; Qulipta for preventive use) and requires trials of standard comparator therapies in line with clinical trial practice — triptans for acute migraine and agents such as antiepileptic drugs, beta-blockers, or antidepressants for preventive therapy — before coverage is granted under step therapy.

References include the manufacturers’ package inserts and professional guidance: Nurtec ODT [package insert] (April 2022); Ubrelvy [package insert] (March 2021); Qulipta [package insert] (April 2023); Zavzpret [package insert] (March 2023); and relevant American Headache Society and American Academy of Neurology guidance documents.

Definitions: Initial limit / Quantity limit — specified month and 3-month maximum dispensing quantities per drug and strength with dispensing mapped to fill-period days (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. Quantity-limit examples in the policy include Nurtec ODT and Ubrelvy: 16 tablets per month / 48 tablets per 3 months; Qulipta: 30 tablets per month / 90 tablets per 3 months; Zavzpret: 6 nasal spray units per 3 weeks / 24 units per 3 months. Pharmacies may dispense manufacturer package sizes up to these limits.