CGRP receptor antagonists are indicated in this request form for three clinical indications: migraine prophylaxis, acute migraine treatment, and cluster headache, using diagnostic definitions from the ICHD‑3. The form operationalizes UnitedHealthcare Washington’s prior authorization process by specifying required documentation, prior medication trials, contraindications, objective measures of response, and submission instructions to support coverage decisions.
To initiate or continue therapy, the prescriber must complete the entire form, include supporting chart notes, and provide a prescriber signature; fax the completed form and chart notes to 866‑940‑7328 and allow at least 24 hours for review. The form asks whether the request is a continuation of existing therapy and requires the diagnosis to be indicated using ICHD‑3 definitions.
For initial prophylaxis requests the form requires the patient’s current weight (kg) and date measured, documentation of the number of migraines per month, and either trials of preferred CGRP agents on the Apple Health Preferred Drug List (or an explanation why preferred products were not tried) plus evidence of failure or contraindication to preventative medication classes (examples listed include candesartan; topiramate, divalproex sodium or valproate; venlafaxine, amitriptyline, nortriptyline or duloxetine; and beta‑blockers such as propranolol, metoprolol, timolol or atenolol). The form also asks whether the CGRP antagonist will be used in combination with other CGRP agents (with an exception for rimegepant ≤ 8 tablets per 30 days).
For initial acute migraine requests the form requires documentation of at least two moderate‑to‑severe migraine episodes per month over the last 3 months, prior trials of preferred acute CGRP agents (or explanation why not tried), whether therapy will be combined with other CGRP antagonists, and evidence of failure or contraindication to other acute agents (e.g., at least two different 5‑HT receptor agonists, a triptan plus an NSAID, or documentation that NSAIDs or triptans are contraindicated).
For cluster headache initial requests the form requires diagnosis per ICHD‑3 and documentation of a trial and failure of verapamil at a total daily dose of at least 360 mg for ≥ 1 month, or an explanation of contraindication; the form also asks whether the CGRP antagonist will be used in combination with other CGRP agents.
Reauthorization (continuation) is supported only with objective documentation of clinical benefit: for prophylaxis, either a reduction in migraine days of at least 40% from baseline or a significant improvement on a quality‑of‑life measure (example: a ≥ 6‑point reduction on HIT‑6); for acute treatment, a clinically meaningful reduction in pain or migraine‑associated symptoms after administration; and for cluster headache, reduction in total headache attacks per week compared to baseline plus the provider’s attestation that therapy is still needed.
The form requires the prescriber to indicate whether medication overuse headache (MOH) has been ruled out for migraine diagnostic consideration, and it emphasizes that chart notes are required with the request and that reauthorization should include documentation of the clinical response per the applicable criteria.
Requests that lack required information—such as weight, trial documentation, chart notes, or the prescriber signature—may be delayed or not approved; non‑preferred product requests must list prior preferred CGRP trials and durations or provide an explanation if preferred agents were not tried.
Overall, this form defines the specific operational requirements and objective thresholds UnitedHealthcare Washington uses to evaluate initial and reauthorization requests for CGRP receptor antagonists across migraine prophylaxis, acute treatment, and cluster headache.