CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid_Ubrelvy_20250730

Defines prior authorization criteria for Medicaid coverage of oral Ubrelvy (ubrogepant) for acute migraine treatment, including initial (6-month) and continuation/renewal (12-month) authorization conditions and quantity limits with exception criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid_Ubrelvy_20250730

Policy CodePolicy N/A

Change TypeReviewed (no material clinical change)

Effective DateOct 1, 2021

Next Review Date

Key ActionSubmit documentation supporting age, prescriber specialty (or consultation), prior inadequate response/intolerance to at least two preferred triptans or contraindication, concurrent preventive therapy for chronic migraine when applicable, and absence of concomitant oral CGRP antagonist use.

SourceLink

POLICY UPDATE CHANGES

Reviewed July 2021, Feb 2022, May 2023, Jun 2024, Jul 2025; package insert referenced June 2025.

10Standard quantity limit

16Maximum post-limit qty

≥2Required failed/intolerant triptans

≥18Minimum age

Coverage Summary & Scope

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This policy addresses Medicaid prior authorization clinical and quantity-limit criteria for oral ubrogepant (Ubrelvy) for the acute treatment of migraine. It defines requirements for initial authorization (6 months) and continuation/renewal authorization (12 months), and specifies standard and post-limit quantity limits and exception criteria. Key elements include age, prescriber specialty or consultation, required prior trial or contraindication to preferred triptans, concurrent preventive therapy for chronic migraine, prohibition of concomitant use with another oral CGRP antagonist, and a standard quantity limit of 10 tablets per 30 days with an exception pathway up to 16 tablets per 30 days.

Key thresholds and limits

Age>=18 years

Quantity limit (standard)10 tablets/30 days

Quantity limit (post-limit maximum)up to 16 tablets/30 days

Chronic migraine definition>=15 headache days per month

Use period before exception10 tablets per 30 days for at least 3 months

Initial Authorization (6 months) - Acute Migraine

Initial Authorization (6 months) - Acute Treatment of Migraine

Authorization for 6 months may be granted when ALL of the following are met:

Age: Patient is 18 years of age or older>= 18 years
Prescriber specialty: Medication is prescribed by, or in consultation with a neurologist or headache specialist
Prior triptan failure or contraindication: Patient has experienced an inadequate treatment response or intolerance to at least two preferred triptan 5-HT1 receptor agonists (e.g., sumatriptan, rizatriptan, naratriptan) or has a contraindication that would prohibit a trial of a triptan 5-HT1 receptor agonist>=2 failed/intolerant preferred triptans
Examples include sumatriptan, rizatriptan, naratriptan
Concurrent preventive therapy for chronic migraine: For patients with a diagnosis of chronic migraines (experiencing at least 15 headache days per month), documentation is provided that the patient is using a preventive migraine medication concurrently>=15 headache days per month
No concurrent oral CGRP antagonist: Patient is not using medication in combination with another oral CGRP antagonist
Quantity limit: The request is within the quantity limit of 10 tablets for Ubrelvy10 tablets per 30 days
If the request exceeds the quantity limit, refer to quantity limit exception criteria in section III

Continuation / Renewal Authorization (12 months)

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

Documentation of initial criteria if not previously approved: If patient has not been approved for this drug by Neighborhood in the past, clinician must submit documentation that initial criteria is met
No concurrent oral CGRP antagonist: Patient is not using medication in combination with another oral CGRP antagonist
Positive clinical response: Documentation that the patient has experienced a positive clinical response to therapy as demonstrated by a reduction in headache pain, duration and/or severity from baseline
Quantity limit: The request is within the quantity limit of 10 tablets for Ubrelvy10 tablets per 30 days
If the request exceeds the quantity limit, refer to quantity limit exception criteria in section III

Documentation Required

Demonstrate positive clinical response for renewal

For 12-month renewal, submit documentation showing the patient experienced a positive clinical response to ubrogepant. The documentation should demonstrate a reduction in headache pain, duration and/or severity compared with baseline. Also confirm the patient is not using ubrogepant in combination with another oral CGRP antagonist and that the request is within the 10-tablet/30-day quantity limit (or refer to quantity limit exception criteria if exceeding).

Quantity Limit Exception (post-limit up to 16 tablets/30 days)

A quantity limit exception (>10 up to 16 tablets/30 days) may be granted when ALL of the following are met:

Prior utilization: Documentation that the patient has been utilizing 10 tablets per 30 days for at least 3 months with inadequate coverage for acute migraine treatment10 tablets per 30 days for >=3 months
Optimized dosage strength: Documentation that the optimized dosage strength of Ubrelvy is being utilized based on tolerability
Concurrent preventive medication for chronic migraine: Documentation that the patient is using a preventative migraine medication concurrentlyapplies particularly to chronic migraine (>=15 headache days/month)
This applies particularly to patients with chronic migraines (>=15 headache days/month)

Prior Authorization

Quantity limit exception documentation

When requesting more than the standard 10 tablets per 30 days (up to 16 tablets/30 days), provide documentation that the patient has been using 10 tablets per 30 days for at least 3 months with inadequate coverage for acute migraine treatment, that the optimized dosage strength of Ubrelvy is being used based on tolerability, and that the patient (particularly if chronic migraine) is using a preventive migraine medication concurrently as applicable.

Prior Authorization & Documentation Requirements

Prior Authorization

Prior authorization required with clinical documentation

Prior authorization requires submission of clinical documentation to support use of ubrogepant for acute migraine. Provide: patient age (≥18 years); that the medication is prescribed by or in consultation with a neurologist or headache specialist; documentation of prior inadequate response or intolerance to at least two preferred triptan 5-HT1 receptor agonists (or documentation of a contraindication to triptans); for chronic migraine (≥15 headache days/month), documentation that the patient is using a preventive migraine medication concurrently; confirmation the patient is not using ubrogepant in combination with another oral CGRP antagonist; and that the request is within the 10-tablet/30-day limit (or include quantity limit exception documentation if requesting >10 up to 16 tablets).

Patient age ≥ 18 years
Prescribed by or in consultation with a neurologist or headache specialist
Inadequate response or intolerance to ≥2 preferred triptans (or contraindication)
If chronic migraine (≥15 headache days/month), concurrent preventive migraine therapy documented
Not using another oral CGRP antagonist concomitantly
Request within 10 tablets/30 days (or include quantity limit exception documentation for >10–16 tablets)

Prior Authorization

Quantity limit exception documentation; Demonstrate positive clinical response for renewal

When seeking a quantity limit exception (>10 up to 16 tablets/30 days), include documentation as described above: at least 3 months of using 10 tablets/30 days with inadequate coverage, and that optimized dosage strength is being used based on tolerability. For renewals, include documentation of positive clinical response (reduction in headache pain, duration and/or severity from baseline).

Background & Definitions

Background: Ubrelvy (ubrogepant) is an oral CGRP receptor antagonist indicated for the acute treatment of migraine. The policy is intended to set clinical and quantity-limit criteria for Medicaid coverage, including a required step through at least two preferred triptan 5-HT1 receptor agonists (or documentation of contraindication), requirements that the medication be prescribed by or in consultation with a neurologist or headache specialist, and documentation of concurrent preventive therapy for patients meeting the definition of chronic migraine (≥15 headache days per month).

Term	Definition
Chronic migraines
Experiencing at least 15 headache days per month
Preferred triptan 5-HT1 receptor agonists
Examples include sumatriptan, rizatriptan, naratriptan