CurrentUnitedHealthcarePolicy 2025 P 2188-9

Reyvow® (lasmiditan) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Defines UnitedHealthcare Commercial Plans prior authorization and medical necessity criteria for Reyvow (lasmiditan) for acute treatment of migraine in adults, including required prior trials, prescriber attestations, reauthorization criteria, and authorization duration.

Policy Summary

PayerUnitedHealthcare

PolicyReyvow® (lasmiditan) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Policy CodePolicy 2025 P 2188-9

Change TypeAnnual review; criteria updates and prior step edits

Effective DateJun 1, 2025

Next Review Date

Key ActionReyvow requires prior authorization consistent with the listed initial criteria including documented prior trials, prescriber attestation, and prophylactic therapy status.

SourceLink

POLICY UPDATE CHANGES

3/2025 annual review updated list of prophylactic agents and removed prescriber requirement.

3/2022 Added a step through Nurtec ODT and Ubrelvy and noted products typically excluded from coverage.

7/2020 Updated requirement from three triptans to two triptans.

Initial program creation 3/2020.

12Authorization months

>=18Age requirement (years)

2Required triptan trials

Coverage Summary

UnitedHealthcare covers Reyvow (lasmiditan) with criteria for the acute treatment of migraine in adults. The policy applies to commercial plans and requires patients to meet prior authorization and medical necessity criteria, including age (>= 18 years), documented prior therapeutic failure/intolerance or contraindication to required agents, and trials of lower-cost options before Reyvow is approved.

Initial Therapy Criteria

Initial Authorization

Reyvow will be approved based on all of the following criteria:

ALL of the following

Used for acute treatment of migraine
Patient is 18 years of age or older
Prior treatment requirement
- Triptan trials - at least TWO of the following
  - almotriptan (Axert)
  - eletriptan (Relpax)
  - frovatriptan (Frova)
  - naratriptan (Amerge)
  - rizatriptan (Maxalt/Maxalt MLT)
  - sumatriptan (Imitrex)
  - zolmitriptan (Zomig/Zomig-ZMT)
Prescriber attestation
- Prescriber attests patient has been informed Reyvow may result in significant CNS impairment and may impact ability to drive or operate machinery for 8 hours after each dose
- If used concurrently with a benzodiazepine or other drugs that could cause CNS depression, prescriber has completed an assessment of increased risk for sedation and other cognitive and/or neuropsychiatric adverse events
Step therapy / alternative migraine-specific agents tried
- Option A: Trials required
  - Nurtec ODT (rimegepant)
  - Ubrelvy (ubrogepant)
- Option B: Prophylactic therapy or low frequency migraine
  - Either
    Patient is currently treated with one of the following prophylactic therapies
    See list of prophylactic agents below
    Patient has < 4 migraine days per month
- Option C: Frequent migraines with intolerance

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Continuation Therapy Criteria

Reauthorization

Reyvow will be approved for renewal when the following is met:

ALL of the following

Documentation of positive clinical response to therapy

Exclusions / Not Covered

The policy notes that certain products are typically excluded from coverage (added in 3/2022) and explicitly lists products that are typically excluded or may be subject to additional benefit/coverage review in the policy notes.

Applicable Codes

No specific codes listed in policy textmixed

No codes listed

Provider Actions / Authorization Workflow

Prior Authorization

Prior authorization required

Reyvow requires prior authorization consistent with the listed initial criteria including documented prior trials, prescriber attestation, and prophylactic therapy status.

Documentation Required

Document prior trials and dates

Document name and date tried for required triptan trials and for listed prophylactic therapies or rationale for contraindication/intolerance.

Clinical Evidence & Safety Notes

P&T approved the program on the following dates: 3/2020, 7/2020, 2/2021, 7/2021, 3/2022, 10/2023, 3/2024, 3/2025. Safety information in the background notes that sedation was reported up to 8 hours after a single dose of Reyvow and patients should be advised to not drive or operate machinery for at least 8 hours after each dose.

Background & Definitions

Reyvow (lasmiditan) is indicated for the acute treatment of migraine with or without aura in adults and is a serotonin 5-HT1F receptor agonist. UnitedHealthcare requires that lower-cost options be tried prior to coverage of Reyvow and that prior authorization criteria (including required prior trials and prescriber attestations) be met.

Therapeutic failure: Lack of adequate response after at least 3 migraine episodes and a minimum 30-day trial, or documented contraindication or intolerance.

Revision History

3/2025annual review - revisedLatest

Annual review updated list of prophylactic agents and removed prescriber requirement.

3/2022revised - step therapy added

Added a step requirement through Nurtec ODT and Ubrelvy and noted products typically excluded from coverage.

7/2020revised - triptan trials reduced

Modified prior triptan trial requirement from three triptans to two triptans.