ModifiedUnitedHealthcarePolicy N/A

Prior Authorization/Medical Necessity — Nurtec ODT, Qulipta, Ubrelvy, Zavzpret (CGRP antagonists)

Prior authorization and medical necessity criteria for rimegepant, atogepant, ubrogepant, and zavegepant in adults with migraine; applies to UnitedHealthcare Pharmacy Clinical Pharmacy Programs.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization/Medical Necessity — Nurtec ODT, Qulipta, Ubrelvy, Zavzpret (CGRP antagonists)

Policy CodePolicy N/A

Change TypeMaterial updates to Qulipta criteria, removal of some CGRP step requirements, and Zavzpret step/documentation changes

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document prior medication trials (drug name, dates, and duration) as specified for the requested agent.

SourceLink

POLICY UPDATE CHANGES

Added footnote for California specific requirement (no trial of non-CGRP preventive treatments required).

Updated Qulipta criteria to allow both episodic and chronic migraines and removed CGRP step for Qulipta.

Removed CGRP step requirement and added provider attestation and updated triptan step for Zavzpret.

5/1/2025policy effective date

12 monthsauthorization duration

≥2-3 agentsprior treatment trials

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.

2Qulipta prior failures required

NCexample states listed

Coverage Criteria for CGRP Receptor Antagonists

Initial Therapy - Ubrelvy

Covered when ALL of the following are met for acute treatment:

Ubrelvy Initial

Indication: Used for acute treatment of migraine
Prior triptan failure: History of therapeutic failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to TWO of the following (document name and date tried): almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan
Prophylactic requirement: One of: (1) Patient is currently treated with a listed prophylactic therapy (e.g., a beta-blocker, candesartan, a preventive CGRP antagonist/inhibitor, divalproex sodium, onabotulinumtoxinA, an SNRI, topiramate, or a tricyclic antidepressant); OR (2) Patient has < 4 migraine days per month; OR (3) Patient has >= 4 migraine days per month and has contraindication or intolerance to one of the listed prophylactic therapies
No concurrent acute CGRP: Medication will not be used in combination with another acute CGRP antagonist (e.g., Nurtec ODT, Zavzpret)

Initial Therapy - Zavzpret

Covered when ALL of the following are met for acute treatment:

Zavzpret Initial

Indication: Used for acute treatment of migraine
Oral triptan failure: History of failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to at least ONE of the listed oral triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan) (document duration of trial)
Nasal spray failure: History of failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to at least ONE of sumatriptan nasal spray or zolmitriptan nasal spray (document drug and date tried)
Oral/sublingual intolerance:

Initial Therapy - Nurtec ODT

Covered when ONE of the following sets of criteria is met (distinct pathways for acute and preventive indications):

Nurtec Pathways

Acute pathway: All of: used for acute treatment of migraine; history of therapeutic failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to TWO listed triptans (document name and date tried); and one of: currently on a listed prophylactic therapy OR patient has < 4 migraine days per month
Preventive pathway: All of: diagnosis of episodic migraine with >= 4 migraine days per month; used for preventive treatment of migraines; history of failure (after a trial of at least two months), contraindication, or intolerance to TWO listed prophylactic therapies (document name and date tried)
Contraindication to other prophylactics pathway: Patient has >= 4 migraine days per month and has contraindication or intolerance to one of the listed prophylactic therapies

Initial Therapy - Qulipta

Covered when ALL of the following are met for preventive treatment:

Qulipta Initial

Diagnosis of migraine consistent with The International Classification of Headache Disorders, 3rd edition (ICHD-3)
Monthly migraine day criteria: One of: (1) 4 to 7 migraine days per month AND at least one of: (a) less than 15 headache days per month OR (b) provider attestation that migraine is the member's predominant headache diagnosis; OR (2) >= 8 migraine days per month

Initial Therapy — Qulipta initial approval

Qulipta initial approval is covered when ALL of the following are met

Qulipta Initial: Member has a diagnosis of migraine consistent with ICHD-3

Migraine frequency: One of the following: (1) 4 to 7 migraine days per month AND at least one of: (a) less than 15 headache days per month OR (b) provider attestation that migraine is the member's predominant headache diagnosis; OR (2) >= 8 migraine days per month

Prior prophylactic therapy: Failure (after a trial of at least two months), contraindication, or intolerance to TWO of the following prophylactic therapies (document name and date tried): beta-blocker (atenolol, metoprolol, nadolol, propranolol, or timolol), candesartan, divalproex sodium, onabotulinumtoxinA, an SNRI (duloxetine, venlafaxine), topiramate, or a tricyclic antidepressant; (for CT, KY, MS only a 30-day trial is required; California exempts non-CGRP preventive trial requirement).>=2 therapies

Reauthorization

Reauthorization covered when ALL of the following are met

Clinical response: Documentation of positive clinical response to therapy

Concomitant acute CGRP restriction: For acute agents, medication will not be used in combination with another acute CGRP antagonist (e.g., Ubrelvy, Zavzpret, Nurtec ODT when used acutely)

Nurtec ODT dual use: Nurtec ODT reauthorization: either (1) use is for acute treatment AND medication is not used in combination with another acute CGRP antagonist; OR (2) use is for preventive treatment AND medication is not used in combination with another preventive CGRP antagonist/inhibitor

Concurrent use of two acute CGRP receptor antagonists is prohibited. The policy specifies that an acute agent (for example, Nurtec ODT, Ubrelvy, or Zavzpret) must not be used in combination with another acute CGRP antagonist when prescribed for the same acute migraine attack or purpose.

Medications covered under this policy must not be used in combination with another CGRP antagonist or inhibitor for the same treatment intent (acute vs preventive). The policy lists examples of prohibited concomitant preventive agents (e.g., Aimovig, Ajovy, Emgality, Nurtec ODT, Qulipta, Vyepti) and directs that preventive- and acute-intent therapies not be combined for the same therapeutic purpose.

Use of a CGRP antagonist or inhibitor in combination with another CGRP agent for the same therapeutic purpose (either acute or preventive) is not medically necessary under this policy and will result in denial or require clinical review. Specifically, requests where the member would receive overlapping CGRP therapies for the same intent (for example, two preventive CGRP agents or two acute CGRP agents) are not allowed.

Clinical Thresholds and Coding Notes

Migraine days per month — eligibility thresholds

Eligibility thresholds4 to 7 migraine days per month AND at least one of: (a) <15 headache days per month OR (b) provider attestation that migraine is the member's predominant headache diagnosis; OR >=8 migraine days per month.

ContextThese frequency thresholds are used to determine initial eligibility for preventive therapy with Qulipta (atogepant).

DocumentationProvider must document migraine day counts and, when applicable, provider attestation that migraine is the predominant headache diagnosis.

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required and will be approved only when drug- and indication-specific criteria are met. Initial authorizations are issued for 12 months. For Qulipta initial approval, diagnosis must meet ICHD-3 criteria and required migraine frequency and prior prophylactic therapy trials (documented name and dates) must be provided. Members must try lower-cost options prior to coverage of Nurtec ODT, Qulipta, Ubrelvy, or Zavzpret.

Initial authorization duration: 12 months
Qulipta requires ICHD-3 diagnosis and documentation of trials of two prophylactic therapies (name and dates)
Program requires members to try lower-cost alternatives prior to coverage

Documentation Required

Provider Documentation Requirements

Providers must document prior medication trials including drug name, dates tried, and duration. For required acute triptan trials and prophylactic therapy trials, note the minimum trial durations where specified (typically minimum 30 days for acute/triptan trials and at least two months for prophylactic agent trials when noted). Failure to include this documentation may result in denial.

Definitions

CGRP antagonist/inhibitor — class and examples

Class definitionCalcitonin gene-related peptide (CGRP) receptor antagonist or inhibitor — agents that target the CGRP pathway for acute or preventive migraine treatment.

Examples (acute)Rimegepant (Nurtec ODT), Ubrogepant (Ubrelvy), Zavegepant (Zavzpret).

Examples (preventive)Atogepant (Qulipta) and CGRP-targeting monoclonal antibodies (examples listed in policy references).

Clinical roleIncludes agents indicated for acute treatment (ubrogepant, rimegepant, zavegepant) and agents indicated for preventive treatment (rimegepant, atogepant, monoclonal antibodies).

ICH D-3 diagnosis (ICHD-3)

TermInternational Classification of Headache Disorders, 3rd edition (ICHD-3).

Background

Nurtec ODT (rimegepant), Ubrelvy (ubrogepant), and Zavzpret (zavegepant) are calcitonin gene-related peptide (CGRP) receptor antagonists approved for the acute treatment of migraine. Nurtec ODT additionally has an approved preventive indication, and Qulipta (atogepant) is indicated for preventive treatment of episodic migraine; the policy aligns prior authorization and treatment-pathway requirements with those indications and with established headache diagnostic criteria such as ICHD-3.

Revision History

2025-02-01material_changeLatest

Added footnote for California-specific requirement (no trial of non-CGRP preventive treatments required).

2024-06-01material_change

Removed CGRP step for Qulipta (operationally removed requirement to step through preventive CGRPs).

2023-12-01material_change

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization/Medical Necessity — Nurtec ODT, Qulipta, Ubrelvy, Zavzpret (CGRP antagonists)

Policy CodePolicy N/A

Change TypeMaterial updates to Qulipta criteria, removal of some CGRP step requirements, and Zavzpret step/documentation changes

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and document prior medication trials (drug name, dates, and duration) as specified for the requested agent.

SourceLink

On This Page

Provider attests patient is not a candidate for oral or sublingual CGRPs (e.g., nausea/vomiting, gastroparesis, inability to swallow)

Prophylactic requirement: One of: (1) Patient is currently treated with a listed prophylactic therapy (e.g., beta-blocker, candesartan, preventive CGRP, divalproex, onabotulinumtoxinA, SNRI, topiramate, tricyclic); OR (2) Patient has < 4 migraine days per month; OR (3) Patient has >= 4 migraine days per month and has contraindication or intolerance to one of the listed prophylactic therapies

No concurrent acute CGRP: Medication will not be used in combination with another acute CGRP antagonist (e.g., Nurtec ODT, Ubrelvy)

No concurrent CGRP: Medication will not be used in combination with another acute CGRP antagonist (e.g., Ubrelvy, Zavzpret) and will not be used in combination with another CGRP antagonist or inhibitor for preventive treatment (e.g., Aimovig, Ajovy, Emgality, Qulipta, Vyepti)

Concomitant therapy restriction: Medication will not be used in combination with another CGRP antagonist or inhibitor used for preventive treatment of migraines (e.g., Aimovig, Ajovy, Emgality, Nurtec ODT, Vyepti, Qulipta)

Document drug name(s), start and end dates (or date tried), and duration for each required trial
Minimum trial durations: acute/triptan trials — minimum 30 days; prophylactic therapy trials for Qulipta — at least 2 months unless otherwise specified
Failure to document therapeutic trials (names, dates, durations) may trigger denial for Ubrelvy, Zavzpret, Nurtec ODT, Qulipta and other products

Note

Try Lower-cost Options and Triptans First

Program requires members to try specified lower-cost options and triptans (or provide documentation of contraindication or intolerance) prior to coverage for the listed CGRP agents. Providers must attest to inability to use oral/sublingual CGRPs for Zavzpret when applicable.

Lower-cost options per guideline include NSAIDs, nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations for mild–moderate attacks
Triptan step: document failure (after ≥3 migraine episodes and minimum 30-day trial), contraindication, or intolerance to the specified triptans
Zavzpret: provider attestation required if patient is not a candidate for oral or sublingual CGRPs (e.g., due to nausea/vomiting, gastroparesis, inability to swallow)

Step Therapy

Step Therapy Notes

Step therapy logic varies by product. Examples of operational variations: Zavzpret requires documented failure of oral triptans and nasal triptan options; Nurtec ODT and Ubrelvy require documented failures of two oral triptans; Qulipta may require prior preventive therapy trials (two prophylactic agents) and is not to be used in combination with another preventive CGRP. Changes to step requirements (e.g., removal or addition of steps through other CGRP products, substitutions such as Nurtec ODT step for Qulipta) should be followed as per current policy effective date.

Nurtec ODT/Ubrelvy: document failure, contraindication, or intolerance to two oral triptans (name and date tried) after ≥3 migraine episodes and ≥30‑day trial
Zavzpret: document failure, contraindication, or intolerance to one oral triptan (≥30‑day trial) and to one nasal triptan (≥30‑day trial) as applicable; include provider attestation if oral/sublingual CGRPs are not appropriate
Qulipta: requires failure (after ≥2 months trial) of two prophylactic therapies (document name and dates); medication must not be used with another preventive CGRP
Operational note: step logic has been updated historically (e.g., removal of injectable CGRP step, addition of Nurtec ODT step for Qulipta, product-specific exceptions); follow the policy effective 2025-05-01

Usage in policyDiagnosis of migraine consistent with ICHD-3 is required for Qulipta initial approval.

ReferenceSee International Headache Society, Headache Classification Committee: The International Classification of Headache Disorders, 3rd edition (Cephalalgia 2018).

Removed CGRP step requirement for Zavzpret, added provider attestation and updated the triptan step for Zavzpret (also removed notation that Zavzpret is typically excluded from coverage).

2023-07-01material_change

Added Zavzpret to the prior authorization program and updated Qulipta criteria to allow both episodic and chronic migraines (included Botox as a preventive option).

2020-07-01operational_change

Modified requirement from three triptans to two triptans and modified concomitant CGRP language in the program.