CurrentUnitedHealthcarePolicy N/A

Prior Authorization Criteria for Preventative Migraine Therapies (CGRP and Related Agents)

NC Medicaid prior authorization criteria and forms for preventative migraine therapies including injectable CGRP monoclonal antibodies (Aimovig, Ajovy, Emgality, Vyepti) and oral agents (Nurtec ODT, Qulipta); applies to prescribers requesting initial or re-authorization coverage for beneficiaries in NC.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Criteria for Preventative Migraine Therapies (CGRP and Related Agents)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed PA form with diagnosis per ICHD criteria, documentation of >=4 migraine days/month for ≥3 months, prior therapy trials, and required administrative details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Up to 3 moInitial approval (most injectables)

Up to 6 moAjovy quarterly dosing

Up to 12 moRe-authorization max

≥4 days/moFrequency threshold

≥2 oral classes

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Prior trials for injectables

Coverage Criteria for Preventive Migraine Therapies

Initial Injectable Therapy

Covered when ALL of the following are met for injectable preventative agents (Aimovig, Ajovy, Emgality, Vyepti):

Eligibility

Frequency: Has experienced >=4 migraine days per month for at least 3 months>=4 days/month x >=3 months
Prior therapies: Tried and failed at least a month or greater trial of medications from at least 2 different oral medication classes (antidepressants, beta blockers, anti-epileptics, ACEi/ARBs, calcium channel blockers)>=2 classes
List medications tried must be provided
MOH: No medication over-use headache (MOH)

Initial Oral Therapy

Covered when ALL of the following are met for oral preventative agents:

Eligibility: Beneficiary has a diagnosis of migraine with or without aura per International Classification of Headache Disordersage >=18

Frequency: Has experienced >=4 migraine days per month for at least 3 months>=4 days/month x >=3 months

Prior therapies: Has tried and failed at least 2 preferred injectable CGRPs (for orals)>=2 preferred injectable CGRPs

Nurtec: check CYP3A4 inhibitor coadministration and renal impairment (CrCl <15 mL/min)

Episodic Cluster Headache (Emgality)

Covered when ALL of the following are met for episodic cluster headache treatment with Emgality:

Diagnosis: Beneficiary has a diagnosis of episodic cluster headache

Cluster history: Has experienced 2 cluster periods lasting 7 days to 1 year (when treated) separated by pain-free remission periods of at least 3 months>=2 cluster periods

Age >=18; pregnancy testing for women of childbearing potential

Dosing: Receiving no more than 300 mg at onset (administered as three consecutive 100 mg injections) then monthly until end of cluster period<=300 mg at onset

Re-authorization

Re-authorization covered when ALL of the following are met:

Clinical response: Significant decrease in number, frequency, and/or intensity of headaches and/or decrease in the length of the cluster perioddocumented improvement

Functional improvement: Overall improvement in function with therapydocumented improvement

Ongoing interventions: Continues to utilize prophylactic intervention modalities (behavioral therapy, physical therapy, lifestyle modifications)

Safety monitoring: Provider continues to monitor pregnancy status for women of childbearing age (not required for Qulipta or Nurtec)

Check for product-specific contraindications before approving Nurtec (rimegepant). The PA form queries concurrent use with a strong CYP3A4 inhibitor and whether the beneficiary has end-stage renal disease with creatinine clearance <15 mL/min; affirmative responses to these items may exclude Nurtec use and should be documented in the clinical record.

Requests are not supported when the form shows the beneficiary does not meet the stated eligibility or safety criteria. Specifically, therapy is not covered if the beneficiary is younger than 18 years, does not have a documented diagnosis of migraine (or episodic cluster headache when applicable) per the International Classification of Headache Disorders, has evidence of medication over‑use headache (MOH), or fails to meet the migraine frequency threshold of >=4 migraine days per month for at least 3 months. For oral agents (Nurtec, Qulipta), requests are also unsupported if the required prior trials of preferred injectable CGRPs are not documented.

Clinical Thresholds and Coding-Related Criteria

Migraine frequency threshold

Required frequency>= 4 migraine days per month for at least 3 months

Duration documentedFrequency must be present for at least 3 months

Age requirement linkMust meet age >=18 as part of eligibility

Re-authorization assessment

Clinical improvement requirementDocumented significant decrease in number, frequency, and/or intensity of headaches or decrease in cluster period length

Functional improvementDocumented overall improvement in function with therapy

Maximum re-authorization duration

Provider Authorization Steps, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required and Approval Durations

Prior authorization is required for initial and re-authorization requests for injectable preventive migraine therapies. Initial injectable approvals: up to 3 months for monthly-dosed agents (Aimovig, Emgality, Ajovy) and up to 6 months for Ajovy quarterly dosing. Re-authorization approvals can be issued for up to 12 months.

Applies to Aimovig, Ajovy, Emgality (120 mg/mL), and Vyepti
Initial injectable approval durations: monthly agents up to 3 months; Ajovy quarterly dosing up to 6 months
Re-authorization duration: up to 12 months

Denial Risk

Initial Injectable Authorization Denial Triggers

For initial injectable requests, denial is likely when required clinical and prior-therapy criteria are not met. Common denial triggers include missing documentation of an ICHD migraine diagnosis, age <18, evidence of medication over-use headache without appropriate management, lack of required prior oral medication trials (two different classes), or absence of a negative baseline pregnancy test when applicable.

Background and Purpose

This PA form is used to authorize preventative headache therapies including injectable CGRP monoclonal antibodies (Aimovig, Ajovy, Emgality, Vyepti) and specified oral agents (Nurtec ODT, Qulipta). It collects diagnostic confirmation per the International Classification of Headache Disorders, age and safety screening (including pregnancy testing for women of childbearing potential), headache frequency (the policy requires >=4 migraine days per month for at least 3 months for preventive treatment), prior preventive therapy trials, and medication‑specific safety checks to determine appropriateness for initial or re‑authorization coverage.

Key Definitions

Medication over-use headache (MOH)

DefinitionMedication over‑use headache (MOH) — a condition queried on the PA form that, if present, may affect appropriateness of preventive therapy

Relevance to coveragePresence of MOH is a denial risk and makes preventive therapy not supported until addressed

Assessment pointForm requires documentation whether beneficiary has MOH before approving preventive agents

Preventative treatment

DefinitionPreventative treatments — therapies intended to reduce frequency, intensity, or duration of migraine or cluster headache episodes, including injectable CGRP monoclonal antibodies and specified oral agents

Examples includedInjectable CGRPs: Aimovig, Ajovy, Emgality, Vyepti; Oral agents: Nurtec ODT, Qulipta

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Criteria for Preventative Migraine Therapies (CGRP and Related Agents)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed PA form with diagnosis per ICHD criteria, documentation of >=4 migraine days/month for ≥3 months, prior therapy trials, and required administrative details.

SourceLink

On This Page

Tolerability: Beneficiary is not experiencing unacceptable toxicity (e.g., intolerable injection site pain, constipation)

Re-authorizations can be approved for up to 12 months

Ongoing interventionsContinued use of prophylactic intervention modalities (behavioral therapy, PT, lifestyle modifications) expected

No documentation of migraine diagnosis per International Classification of Headache Disorders (ICHD)
Beneficiary age < 18 years
Medication over-use headache (MOH) without documentation of management
Failure to document trials of oral preventive medications from at least two different classes
No baseline negative pregnancy test for women of childbearing potential when required

Documentation Required

Required Administrative Documentation

Providers must supply complete administrative information with the authorization request to avoid processing delays or denial.

Beneficiary full name, date of birth, gender, and member ID
Prescribing provider name and NPI
Requester contact name and phone number (with extension if applicable) and address
Drug name, strength, quantity per 30 days, and requested length of therapy (days)
Prescriber signature and date (prescriber signature mandatory)

Documentation Required

Required Clinical Documentation

Clinical documentation must accompany initial and re-authorization requests to demonstrate medical necessity and meet policy criteria.

Documentation of migraine diagnosis meeting ICHD criteria (with or without aura)
Age documentation showing beneficiary is ≥ 18 years
For women of childbearing potential: negative pregnancy test at baseline (when applicable) and ongoing monitoring for re-authorization as noted
Migraine diary or documentation showing ≥ 4 migraine days per month for at least 3 months (when required)
Assessment for medication over-use headache (MOH) and evidence of management if present
Documentation of use of prophylactic non-pharmacologic interventions where applicable (behavioral therapy, physical therapy, lifestyle modifications)
For re-authorization: documentation of clinical benefit (decrease in number/frequency/intensity of headaches, improved function) and absence of unacceptable toxicity

Step Therapy

Required Prior Medication Trials

Prior medication trials must be documented per therapy type before approval.

For injectables: documentation of trial and inadequate response or intolerance to medications from at least 2 different oral preventive medication classes (examples: antidepressants such as amitriptyline or venlafaxine; beta blockers such as propranolol or metoprolol; anti-epileptics such as valproate or topiramate; ACE inhibitors/ARBs such as lisinopril or candesartan; calcium channel blockers such as verapamil) with at least a one-month trial each
For orals (Nurtec ODT, Qulipta): documentation of trial/failure of 2 preferred injectable CGRPs when required (per form), and specific Nurtec considerations (concurrent use with strong CYP3A4 inhibitors and renal function/CrCl <15 mL/min)

PurposeUsed for prophylactic management when eligibility criteria (diagnosis, frequency, prior trials) are met