ModifiedUnitedHealthcarePolicy 2025 P 3145-11

UnitedHealthcare Pharmacy Clinical Pharmacy Programs

Defines step therapy/prior authorization requirements for acute and preventive migraine therapies (Nurtec ODT/rimegepant, Qulipta/atogepant, Ubrelvy/ubrogepant, Zavzpret/zavegepant) across UnitedHealthcare pharmacy programs, effective 2025-05-01; includes trial/failure requirements, durations, approvals and program change history.

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealthcare Pharmacy Clinical Pharmacy Programs

Policy CodePolicy 2025 P 3145-11

Change TypeStep therapy program established/modified

Effective DateMay 1, 2025

Next Review Date

Key ActionPrior authorization/step therapy required: document trials, failures, contraindications, or intolerances (names and dates tried) to specified lower-cost/triptan or preventive therapies before Nurtec ODT, Qulipta, Ubrelvy or Zavzpret will be approved.

POLICY UPDATE CHANGES

Program effective 5/1/2025 establishing step therapy for Nurtec ODT, Qulipta, Ubrelvy, Zavzpret.

Condensed acute criteria for Nurtec ODT and Ubrelvy and updated triptan step for Zavzpret (12/2021–12/2023 revisions culminating in Zavzpret added and triptan adjustments).

Removed CGRP step for Qulipta and updated prophylactic therapy lists (8/2024 and earlier).

Added California-specific footnote regarding preventive treatment trial requirement (2/2025).

4Medications in program

12Authorization months

2Preventive therapy failures required

3Acute triptan trial episodes required

Summary of changes and impact

Effective 2025-05-01, the program establishes step therapy requirements for Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant) and Zavzpret (zavegepant). Members must trial and document failures, contraindications, or intolerances to specified lower‑cost triptans or preventive therapies prior to coverage of these CGRP-targeting and gepant migraine therapies.

The program includes material changes: formal establishment of the step therapy program effective 5/1/2025 and revisions removing certain CGRP steps for at least Qulipta, updating triptan examples (including addition of Zomig‑ZMT), condensing acute criteria for Nurtec ODT and Ubrelvy, and adding Zavzpret with a nasal spray triptan requirement. Historical P&T actions through 2/2025 show iterative modifications culminating in these changes.

Zavzpret criteria specifically require prior trial/failure of an oral triptan AND a nasal spray triptan (sumatriptan or zolmitriptan). The program notes state and benefit variations: for California business a trial of non‑CGRP preventive treatments will not be required; other states may have different shorter preventive trial requirements.

Authorization for approved therapies will be issued for 12 months. These changes were reviewed and recorded in P&T actions from 9/2020 through 2/2025 leading to the current effective date.

Key program facts

Medications in program4

Authorization months12

Preventive therapy failures required2

Acute triptan trial episodes required3

Effective date2025-05-01

Policy number2025 P 3145-11

Coverage and approval criteria

D. Other Diagnoses

Covered when the following applies:

Ubrelvy, Nurtec ODT, Qulipta or Zavzpret will be approved for other diagnoses (unspecified) - Authorization issued for 12 months.

Drugs addressed by this policy

Drugs addressed by policymixed

	Nurtec ODT (rimegepant)
	Qulipta (atogepant)
	Ubrelvy (ubrogepant)
	Zavzpret (zavegepant)

What providers must do

Prior Authorization

Prior authorization / Step therapy required

Prior authorization or step therapy is required for coverage of Nurtec ODT, Qulipta, Ubrelvy, and Zavzpret. Providers must submit documentation of required prior trials, failures, contraindications, or intolerances as specified by the policy.

Affected products: Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), Zavzpret (zavegepant)
Required documentation of prior trials, failures, contraindications, or intolerances

Documentation Required

Document trials, dates, durations, and reasons

Document the specific drug tried, the start and end dates (or date tried), the duration of the trial, and the clinical reason the trial failed (e.g., lack of efficacy, adverse effect, or contraindication).

Definitions and thresholds

Trial of failure: documented therapeutic failure after a specified trial duration, contraindication, or intolerance to the drug(s) tried.

Operational notes: for acute oral triptans the program requires trials after at least 3 migraine episodes and a minimum of a 30‑day trial per agent; for preventive therapies the program generally requires a trial of at least two months (some states—Connecticut, Kentucky, Mississippi—require only a 30‑day preventive trial).

Documentation must include the drug name, dates tried, trial duration and reason for failure/contraindication/intolerance as part of the prior authorization process.

Thresholds and durations

Migraine episodes trial (acute)At least 3 migraine episodes (acute approval)

Oral triptan trial durationMinimum 30-day trial

Nasal triptan trial requirement (Zavzpret)History of failure to a nasal sumatriptan or zolmitriptan after a minimum 30-day trial

Preventive therapy trial duration

Supporting evidence and review history

Evidence and references supporting the program include P&T approval actions dated from 9/2020 through 2/2025 and cited source materials: manufacturer package inserts (2023), the American Headache Society Consensus Statement (2024), and ICHD‑3 (2018).

The program language and changes reference these guideline positions and package inserts when defining step requirements, trial durations, and the list of comparator triptans and preventive therapies.

Evidence and references

P&T Approval Dates range9/2020 through 2/2025

References citedManufacturer package inserts (2023); AHS Consensus Statement (2024); ICHD‑3 (2018)

Document changes and timeline

9/2020added

Program created (new step therapy program for Nurtec ODT, Qulipta, Ubrelvy, Zavzpret).

7/2021review

Annual review; added prevention of episodic migraines for Nurtec ODT, updated trial language to include 3 migraine episodes and references.

12/2021added

Qulipta added for preventive treatment of migraines; references updated.

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealthcare Pharmacy Clinical Pharmacy Programs

Policy CodePolicy 2025 P 3145-11

Change TypeStep therapy program established/modified

Effective DateMay 1, 2025

Next Review Date

On This Page

Minimum trial durations: 30 days for oral triptans (acute therapy)

Minimum preventive trial duration: 2 months for prophylactic therapies (except where state-specific exceptions apply)

For acute triptan trials document trial duration and dates tried

Prior Authorization

Authorization duration

Approvals granted under this program are issued for a finite period and require re‑authorization thereafter.

12 months
Re-authorization requires submission of updated documentation consistent with initial criteria

Denial Risk

Denial risk if documentation absent

If required trial documentation is not provided, the request may be denied. UnitedHealthcare may use claims, medication history, diagnosis (ICD-10) codes, and automated logic to approve or re-authorize requests when available, but absence of documentation creates denial risk.

Requests lacking documented trials, dates, durations, or reasons for failure may be denied
UnitedHealthcare may rely on claims/medication history and diagnosis codes for automated approvals when applicable

Billing Rule

State and benefit plan variations

State mandates and member-specific benefit plans can modify the trial requirements and durations for these therapies; document care accordingly and verify applicable mandates for the member.

Connecticut, Kentucky, Mississippi: only a 30-day preventive trial required (instead of the standard 2 months)
California: a trial of non‑CGRP preventive treatments is not required for certain approvals
Member benefit plans and federal requirements may further affect criteria

At least 2 months (exceptions: CT, KY, MS = 30 days)

State exceptionsConnecticut, Kentucky, Mississippi: 30-day preventive trial; California: no non-CGRP preventive trial required

3/2022revised

Removed step through injectable CGRPs for Nurtec ODT; added step through Nurtec ODT for Qulipta; updated products typically excluded from coverage and references.

3/2023updated

Updated state mandate language; annual review.

7/2023revised

Added Zomig-ZMT as a triptan example and updated references.

12/2023revised

Condensed acute criteria for Nurtec ODT and Ubrelvy; removed CGRP step and updated triptan step for Zavzpret; Zavzpret added earlier and triptan adjustments made during 12/2021–12/2023 revisions.

6/2024revised

Removed notation that Zavzpret is typically excluded from coverage; references updated.

8/2024revised

Removed CGRP step for Qulipta; updated Zavzpret step and list of potential prophylactic therapies.

2/2025added

Added California-specific footnote: for California business a trial of non-CGRP preventive treatments will not be required.

5/1/2025effectiveLatest

Program effective establishing step therapy requiring trial/failure of specified lower-cost triptans or prophylactic therapies prior to coverage of Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), and Zavzpret (zavegepant); material changes include condensed acute criteria, removal of CGRP steps, triptan example updates (including Zomig‑ZMT and nasal spray requirement for Zavzpret), removal of Qulipta exclusion notation, and California-specific footnote.