CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Ubrelvy (ubrogepant) — Acute Treatment of Migraine (coverage criteria)

Policy governs prior authorization and coverage criteria for Ubrelvy (ubrogepant) as acute treatment for migraine for adult members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUbrelvy (ubrogepant) — Acute Treatment of Migraine (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2021

Next Review Date2025-07

Key ActionObtain prior authorization documenting patient is ≥18, prescribed by or in consultation with a neurologist/headache specialist, and has trialed or has contraindication to at least two preferred triptans.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+minimum patient age

10/mostandard quantity limit

≤16/mopost-limit max

12 mocontinuation auth

Coverage Criteria for Ubrelvy (ubrogepant)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUbrelvy (ubrogepant) — Acute Treatment of Migraine (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2021

Next Review Date2025-07

SourceLink

On This Page

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Initial criteria: Patient is 18 years of age or older; Medication is prescribed by, or in consultation with a neurologist or headache specialist; For patients with a diagnosis of chronic migraines (≥15 headache days/month), documentation that the patient is using a preventive migraine medication concurrently; Patient has experienced inadequate treatment response or intolerance to at least two preferred triptans (sumatriptan, rizatriptan, naratriptan) or has a contraindication to triptans; Patient is not using Ubrelvy in combination with another oral CGRP antagonist; The request is within the quantity limit of 10 tablets for Ubrelvy (unless quantity limit exception criteria are met); If the request exceeds the quantity limit, refer to the quantity limit exception criteria in section III.

All conditions required for initial 6-month approval

Continuation Authorization

Authorization for 12 months may be granted when ALL of the following are met

Continuation criteria: Patient meets initial criteria or has prior Neighborhood approval; Patient is not using Ubrelvy in combination with another oral CGRP antagonist; Request is within the quantity limit of 10 tablets per 30 days for Ubrelvy (unless quantity limit exception applied); Documentation of positive clinical response demonstrated by reduction in headache pain, duration and/or severity from baseline; If request exceeds the quantity limit, see quantity limit exception criteria which requires documentation of utilization of 10 tablets per 30 days for at least 3 months and that optimized dose strength is being used.

All conditions required for 12-month continuation approval

Requests for Ubrelvy that do not document a trial and inadequate response or intolerance to at least two preferred triptans (sumatriptan, rizatriptan, naratriptan) — unless there is a contraindication to triptans — do not meet medical necessity. The policy also applies only to adults; the patient must be 18 years of age or older. In addition, concurrent use with another oral CGRP antagonist is prohibited and will render the request non‑covered. If the request exceeds the standard quantity limit, the quantity limit exception requirements in section III must be met.

Coding and Quantity Limits

Covered medicationmixedCovered

Ubrelvy

ubrogepant oral tablet (brand name referenced in policy)

inv-06: Quantity limit — Ubrelvy (ubrogepant) — standard and exception

Standard quantity limit10 tablets per 30 days (standard)

Exception maximumUp to 16 tablets per 30 days with supporting documentation

Exception documentation requirementDocumentation must show patient has been utilizing 10 tablets per 30 days for at least 3 months

Dose optimization requirement for exceptionDocumentation that the optimized dosage strength of Ubrelvy is being used based on tolerability

Provider Actions, Documentation, and Denials

Prior Authorization

Prior Authorization Required

Prior authorization is required. Initial approvals are typically granted for 6 months; continuation approvals may be granted for 12 months when continuation criteria are met.

Initial authorization: up to 6 months
Continuation authorization: up to 12 months

Step Therapy

Triptan Trial Requirement

For initial authorization, the patient must have experienced inadequate response or intolerance to at least two preferred triptans or have a documented contraindication to triptans. Preferred triptans include sumatriptan, rizatriptan, and naratriptan.

Trial/failure or intolerance to at least two preferred triptans (e.g., sumatriptan, rizatriptan, naratriptan), OR
Documented contraindication to triptan therapy

Documentation Required

Required Documentation for Authorization

Required documentation must be submitted with the initial authorization request. Include patient age, prescriber specialty or documentation of consultation with a neurologist or headache specialist, diagnosis (including chronic migraine details if applicable), and documentation of prior triptan trials or contraindications. For chronic migraine patients using a preventive medication, include documentation of concurrent preventive therapy and usage of 10 tablets per 30 days for at least 3 months if applicable. When requesting continuation/renewal, include documentation of a positive clinical response (reduction in headache pain, duration and/or severity) and any dosing/quantity details.

Patient age (must be ≥ 18 years for acute treatment)
Prescriber is a neurologist or headache specialist, or documentation of consultation with such a specialist
Diagnosis and headache frequency (for chronic migraine: ≥ 15 headache days/month) and documentation of concurrent preventive therapy when applicable
Documentation of inadequate response or intolerance to at least two preferred triptans, or documented contraindication to triptans
For chronic migraine patients on preventive therapy: documentation of using 10 tablets per 30 days for at least 3 months when applicable
For continuation: documentation of positive clinical response (reduction in pain, duration and/or severity) and current dosing
If requesting quantity above limit, include quantity limit exception rationale (see quantity limit criteria)

Denial Risk

Triggers for Denial

Requests failing to meet the above requirements are at high risk for denial.

Patient under 18 years of age for acute treatment
Prescriber is not a neurologist/headache specialist and no documented consultation
Insufficient documentation of prior triptan trials or contraindication
Lack of documentation of concurrent preventive therapy for chronic migraine when required
Insufficient documentation of positive clinical response for continuation requests
Requests exceeding quantity limits without an approved exception

Background

Ubrelvy (ubrogepant) is an oral calcitonin gene‑related peptide (CGRP) receptor antagonist indicated for the acute treatment of migraine. This policy distinguishes between initial short‑term authorizations and continuation approvals: an initial authorization may be granted for 6 months when all initial criteria are met, and a continuation authorization may be granted for 12 months when continuation criteria (including documented positive clinical response) are satisfied. The policy requires that the medication be prescribed by, or in consultation with, a neurologist or headache specialist and specifies age, prior‑therapy, concurrent‑prevention (for chronic migraine), and quantity‑limit conditions for coverage.

Definitions and Exceptions

inv-12: Chronic migraine definition

DefinitionChronic migraine: diagnosis characterized by at least 15 headache days per month

Relevance to authorizationFor patients with chronic migraine, documentation must show concurrent use of a preventive migraine medication for initial authorization

Age requirementPatient must be 18 years of age or older to qualify

inv-13: Quantity limit exception — criteria and documentation

Exception allowanceQuantity limit exception permits up to 16 tablets per 30 days when criteria are met

Required prior utilizationDocumentation must show the patient has been utilizing 10 tablets per 30 days for at least 3 months

Dose optimizationDocumentation must confirm the optimized dosage strength of Ubrelvy is being used based on tolerability

Where referencedSee Quantity Limit section (III) and policy documentation for continuation/exception criteria