CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Qulipta (atogepant) for migraine prevention

Defines clinical criteria, authorization durations (6- and 12-month), quantity limits and continuation requirements for coverage of Qulipta (atogepant) for prevention of episodic and chronic migraine for Medicaid members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyQulipta (atogepant) for migraine prevention

Policy CodePolicy N/A

Change TypeClarified (review dates and reference updated)

Effective DateOct 1, 2021

Next Review Date

Key ActionPrior authorization required; submit documentation of trials/failures of required prophylactic therapies and clinical response per criteria.

SourceLink

POLICY UPDATE CHANGES

Reviewed dates updated through 07/2025 and package insert reference from June 2025 included.

2Authorization durations (6-month initial, 12-month renewal)

1/dayQuantity limit

4-14Episodic migraine definition (days/mo)

>=15Chronic migraine definition (days/mo)

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.

Coverage stance: Covered with criteria for Qulipta (atogepant) for prevention of episodic and chronic migraine. Scope: Defines clinical criteria, authorization durations (6-month initial, 12-month renewal), quantity limits and continuation requirements for coverage of Qulipta for prevention of episodic and chronic migraine for Medicaid members. Quantity limit: one Qulipta tablet per day (10 mg, 30 mg, or 60 mg). Effective date: 2021-10-01; Last review: 2025-07.

Coverage thresholds / limits

Episodic migraine days>=4 and <=14 headache days per month

Chronic migraine days>=15 headache days per month for at least 3 months

Botulinum toxin prior trialMinimum of 2 quarterly injections (6 months)

Prior prophylactic medication trial duration3-month trial of each of 2 medications

Initial Authorization — Preventative Treatment of Episodic Migraine (6 months)

An authorization for 6 months may be granted when ALL of the following criteria are met:

ALL of the following

Patient is 18 years of age or older
Medication is prescribed by, or in consultation with a neurologist or headache specialist
Patient experiences at least 4 but not more than 14 headache days per month, with disability on some days>=4 and <=14 headache days per month
Patient has been fully equipped with abortive migraine therapy, if appropriate, and has had inadequate relief
See definition: Fully equipped with abortive migraine therapy
Prior prophylactic medication trials
- Examples of classes/drugs: Antidepressants (e.g., amitriptyline, venlafaxine)
- Examples of classes/drugs: Beta blockers (e.g., propranolol, metoprolol, timolol, atenolol)
- Examples of classes/drugs: Anti-epileptics (e.g., topiramate, valproate)
Patient has documented trial and failure of a preferred injectable CGRP antagonist (Ajovy or Emgality) for migraine prevention
Documentation of clinical response as demonstrated by change in headache frequency, duration and/or severity from baseline must be provided
Patient is not using medication in combination with another oral CGRP antagonist, an injectable CGRP antagonist (e.g., Ajovy, Emgality, Vyepti), or a botulinum toxin (e.g., onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, rimabotulinumtoxinB)

Initial Authorization — Preventative Treatment of Chronic Migraine (6 months)

An authorization for 6 months may be granted when ALL of the following criteria are met:

ALL of the following

Patient is 18 years of age or older
Medication is prescribed by, or in consultation with a neurologist or headache specialist
Patient is experiencing at least 15 headache days per month (tension-type-like and/or migrainelike) for at least 3 months>=15 headache days per month for at least 3 months
Patient has been fully equipped with abortive migraine therapy, if appropriate, and has had inadequate relief
See definition: Fully equipped with abortive migraine therapy
Prior prophylactic medication trials
- Examples of classes/drugs: Antidepressants (e.g., amitriptyline, venlafaxine)
- Examples of classes/drugs: Beta blockers (e.g., propranolol, metoprolol, timolol, atenolol)
- Examples of classes/drugs: Anti-epileptics (e.g., valproate, topiramate)
Patient has documented trial and failure to a minimum of 2 quarterly injections (6 months) of botulinum toxin (e.g., onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, rimabotulinumtoxinB)minimum of 2 quarterly injections (6 months)
Documentation of clinical response as demonstrated by change in headache frequency, duration and/or severity from baseline must be provided
Patient has documented trial and failure of a preferred injectable CGRP antagonist (Ajovy or Emgality) for migraine prevention
Documentation of clinical response as demonstrated by change in headache frequency, duration and/or severity from baseline must be provided
Patient is not using medication in combination with another oral CGRP antagonist (e.g., Nurtec ODT, Ubrelvy) or an injectable CGRP antagonist (e.g., Ajovy, Emgality, Vyepti)

Continuation / Reauthorization — Episodic Migraine (12 months)

An authorization for 12 months may be granted when ALL of the following criteria are met:

ALL of the following

If patient has not been approved for this drug by Neighborhood in the past, clinician must submit documentation that initial criteria is met.
Patient is not using medication in combination with another oral CGRP antagonist (e.g., Nurtec ODT, Ubrelvy), an injectable CGRP antagonist (e.g., Ajovy, Emgality, Vyepti), or a botulinum toxin (e.g., onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, rimabotulinumtoxinB)
Patient has experienced a positive clinical response to therapy as demonstrated by a reduction in headache frequency, duration and/or severity from baseline

Continuation / Reauthorization — Chronic Migraine (12 months)

An authorization for 12 months may be granted when ALL of the following criteria are met:

ALL of the following

If patient has not been approved for this drug by Neighborhood in the past, clinician must submit documentation that initial criteria is met.
Patient is not using medication in combination with another oral CGRP antagonist (e.g., Nurtec ODT, Ubrelvy), an injectable CGRP antagonist (e.g., Ajovy, Emgality, Vyepti), or a botulinum toxin (e.g., onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, rimabotulinumtoxinB)
Patient has experienced a positive clinical response to therapy as demonstrated by a reduction in headache frequency, duration and/or severity from baseline
If patient is using medication in combination with a botulinum toxin, the patient has shown a clinically meaningful incremental benefit from using both products.

Provider Actions & Billing Rules

Prior Authorization

Authorization required

Prior authorization required. Initial authorizations are for 6 months; reauthorizations may be granted for 12 months when continuation criteria are met. If the patient has not been previously approved by Neighborhood, the clinician must submit documentation that the initial criteria are met. Documentation should be provided showing eligibility (age, prescriber specialty, headache-day thresholds) and required prior therapy trials as detailed in the policy.

Initial authorization duration: 6 months
Reauthorization duration: 12 months
If not previously approved by Neighborhood, submit documentation that initial criteria are met

Documentation Required

Document prior therapy failures and clinical response

Document trials and failures of required prior prophylactic therapies and objective clinical response. Required documentation includes: trials of two prophylactic oral medications (each a 3-month trial) from classes such as antidepressants (e.g., amitriptyline, venlafaxine), beta blockers (e.g., propranolol, metoprolol, timolol, atenolol), or anti‑epileptics (e.g., topiramate, valproate); failure of preferred injectable CGRP antagonists (Ajovy or Emgality); for chronic migraine, trial and failure of at least two quarterly botulinum toxin injections (minimum 6 months). Provide measures of clinical response such as change in headache frequency, duration and/or severity from baseline.

Document two 3-month trials of oral prophylactic medications (from listed classes)
Document trial and failure of preferred injectable CGRP antagonist (Ajovy or Emgality)
For chronic migraine, document trial and failure of ≥2 quarterly botulinum toxin injections (6 months)
Provide clinical response data: change in headache frequency, duration and/or severity from baseline

Billing Rule

Quantity limit enforcement

Quantity limit enforcement: Qulipta tablets (10 mg, 30 mg, or 60 mg) are limited to one tablet per day.

Limit: 1 tablet per day for 10 mg, 30 mg, and 60 mg strengths

Denial Risk

Concomitant CGRP or botulinum use prohibited

Claims may be denied if Qulipta is used in combination with another oral CGRP antagonist, an injectable CGRP antagonist, or a botulinum toxin. An exception may be considered for chronic migraine when the patient has documented a clinically meaningful incremental benefit from concurrent use of Qulipta with botulinum toxin; documentation of that incremental benefit is required.

Denial risk when combined with another oral CGRP antagonist, injectable CGRP antagonist, or botulinum toxin
Exception for chronic migraine: documented clinically meaningful incremental benefit when combined with botulinum toxin

Background

Background: Qulipta (atogepant) is an oral CGRP receptor antagonist indicated for preventive treatment of episodic migraine. This policy sets prior authorization clinical criteria consistent with trials and comparators, including requirement to trial other prophylactic therapies and preferred injectable CGRPs or botulinum toxin where specified.

Definition: Fully equipped with abortive migraine therapy — Patient has access to and has tried acute/abortive migraine treatments, where appropriate, with inadequate relief.

ScopeDefines clinical criteria, authorization durations (6- and 12-month), quantity limits and continuation requirements for Qulipta for migraine prevention (Medicaid)

StatusCURRENT

SubjectQulipta (atogepant) for migraine prevention

Quantity limitOne tablet per day (10mg, 30mg, or 60mg)

Authorization durationsInitial: 6 months; Renewal: 12 months

Revision History

07/2021reviewed

Policy reviewed (update log entry).

02/2022reviewed

Policy reviewed (update log entry).

07/2023reviewed

Policy reviewed (update log entry).

05/2024reviewed

Policy reviewed (update log entry).

07/2025reviewedLatest

Policy reviewed (latest review date updated through 07/2025).

June 2025reference

Qulipta package insert cited (Qulipta [package insert]. Allergan USA, Inc.; June 2025).

OpenPayer

Qulipta (atogepant) for migraine prevention

Coverage Summary

Initial Authorization — Preventative Treatment of Episodic Migraine (6 months)

Initial Authorization — Preventative Treatment of Chronic Migraine (6 months)

Continuation / Reauthorization — Episodic Migraine (12 months)

Continuation / Reauthorization — Chronic Migraine (12 months)

Provider Actions & Billing Rules

Applicable Codes

Clinical Evidence & References

Background

Revision History