CurrentUnitedHealthcarePolicy N/A

Step therapy for CGRP-targeted and gepant migraine medications

Defines step therapy prior authorization requirements for Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant) and Zavzpret (zavegepant) for acute and preventive migraine treatment for UnitedHealthcare members.

Policy Summary

PayerUnitedHealthcare

PolicyStep therapy for CGRP-targeted and gepant migraine medications

Policy CodePolicy N/A

Change TypeMaterial updates: added Zavzpretrevised acute and preventive step requirements

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization documenting medication names, dates, and trial durations demonstrating required triptan or prophylactic therapy failures before coverage.

SourceLink

POLICY UPDATE CHANGES

Added Zavzpret to the step therapy program and specified its triptan nasal-spray step requirements.

Updated acute criteria to require failure, contraindication, or intolerance to two oral triptans for Nurtec ODT and Ubrelvy and to one oral plus one nasal triptan for Zavzpret.

Updated preventive criteria to require failure, contraindication, or intolerance to two specified prophylactic therapies (minimum 2-month trials) prior to approval of Qulipta and preventive Nurtec ODT.

4medications covered

12 moauth duration

>=30 dacute triptan trial

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Coverage Criteria

Initial acute therapy (Nurtec ODT, Ubrelvy)

Covered when ALL of the following are met:

Acute Nurtec ODT/Ubrelvy approval: 1) History of therapeutic failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to two of the specified oral triptans; 2) Document name and date tried for each agent.two oral triptans; >=30-day trial; >=3 episodes

List of acceptable oral triptans: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan

Initial acute therapy (Zavzpret)

Covered when ALL of the following are met:

Acute Zavzpret approval: 1) History of failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to one of the specified oral triptans (document duration of trial); AND 2) History of failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to one of the specified nasal spray triptans (sumatriptan or zolmitriptan nasal spray); document drug and date tried.one oral triptan and one nasal triptan; >=30-day trial; >=3 episodes

Requires both an oral and a nasal triptan trial

Prevention — Nurtec ODT (episodic migraine)

Covered when ALL of the following are met:

Nurtec ODT prevention approval: History of failure (after a trial of at least two months), contraindication, or intolerance to two of the listed prophylactic therapies; document name and date tried.two prophylactic therapies; >=2-month trials

Acceptable therapies include beta-blockers (atenolol, metoprolol, nadolol, propranolol, timolol), candesartan, divalproex sodium, SNRIs (duloxetine, venlafaxine), topiramate, tricyclic antidepressants (amitriptyline, nortriptyline)

Prevention — Qulipta

Covered when ALL of the following are met:

Qulipta prevention approval: History of failure (after a trial of at least two months), contraindication, or intolerance to two of the listed prophylactic therapies; document name and date tried.two prophylactic therapies; >=2-month trials

Acceptable therapies include beta-blockers, candesartan, divalproex sodium, onabotulinumtoxinA (Botox) [may be subject to additional review], SNRIs (duloxetine, venlafaxine), topiramate, tricyclic antidepressants

Other Diagnoses

Other Diagnoses: Ubrelvy, Nurtec ODT, Qulipta or Zavzpret will be approved for other diagnoses (no additional criteria specified in this policy).none

Statement present but without specified criteria

For members whose coverage is subject to California business mandates, the policy does not require a trial of non-CGRP preventive treatments before approval of Qulipta or preventive Nurtec ODT. This state-specific exception supersedes the standard preventive step-therapy requirement that otherwise requires documented trials of two specified prophylactic therapies of at least 2 months duration.

This policy does not list any medications or indications as explicitly “not medically necessary.” The document’s references and change history note program updates and prior reviews, but no section of the policy text is labeled or titled as a declaration of treatments being “not medically necessary.”

Coding and Trial Duration

Provider Actions & Documentation Requirements

Prior Authorization

Step therapy prior authorization required

Prior authorization is required for Nurtec ODT, Qulipta, Ubrelvy, and Zavzpret. The request must document trials of the specified prior therapies including medication names, dates tried, and duration of each trial; authorizations are issued for 12 months.

Document medication name, date tried, and trial duration for each required prior agent
Authorization duration: 12 months

Step Therapy

Step therapy requirements (failures, contraindications, intolerances)

Providers must document therapeutic failure, contraindication, or intolerance to the required prior agents after at least three migraine episodes and the minimum trial duration specified by indication before coverage will be approved.

Acute (Nurtec ODT/Ubrelvy): failure, contraindication, or intolerance to two specified oral triptans after ≥3 episodes and a ≥30-day trial
Acute (Zavzpret): failure, contraindication, or intolerance to one specified oral triptan AND one specified nasal triptan after ≥3 episodes and a ≥30-day trial

Background

Gepants are small-molecule CGRP receptor antagonists used in migraine management. Examples addressed in this policy include rimegepant (Nurtec ODT), atogepant (Qulipta), ubrogepant (Ubrelvy), and zavegepant (Zavzpret). These agents serve distinct clinical roles: rimegepant and ubrogepant are referenced for acute treatment of migraine attacks, while rimegepant (oral ODT) and atogepant are also indicated for preventive (prophylactic) therapy. The policy’s criteria reflect these roles by setting separate step-therapy and prior trial requirements for acute versus preventive use.

Definitions

CGRP-targeted therapies (gepants)

DefinitionCGRP-targeted therapies (gepants) are calcitonin gene–related peptide (CGRP) receptor antagonists used for acute and/or preventive treatment of migraine

Examples listed in policyNurtec ODT (rimegepant), Ubrelvy (ubrogepant), Zavzpret (zavegepant), Qulipta (atogepant)

Clinical rolesUsed as migraine-specific agents for acute treatment (some agents) and as preventive therapy (rimegepant for prevention; atogepant for prevention)