CurrentUnitedHealthcarePolicy N/A

Reyvow (lasmiditan) — Prior Authorization and Medical Necessity Criteria

Defines UnitedHealthcare prior authorization and medical necessity criteria for Reyvow (lasmiditan) for acute migraine treatment in adults, including initial and reauthorization requirements and drug step therapy expectations.

Policy Summary

PayerUnitedHealthcare

PolicyReyvow (lasmiditan) — Prior Authorization and Medical Necessity Criteria

Policy CodePolicy N/A

Change TypeMaterial revisions: added step requirementupdated prophylactic agent list

Effective DateJun 1, 2025

Next Review DateMar 1, 2025

Key ActionObtain and document trials (names and dates) of two triptans plus both Nurtec ODT and Ubrelvy before requesting authorization.

SourceLink

POLICY UPDATE CHANGES

Updated list of prophylactic agents and removed prescriber requirement from reauthorization.

Added a required step through Nurtec ODT and Ubrelvy prior to Reyvow.

≥18minimum patient age for approval

2 triptans + Nurtec ODT + Ubrelvyrequired acute therapy trials/steps

12 moauthorization period

positive responsereauthorization criterion

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Initial Authorization

Reyvow is covered when ALL of the following are met:

Indication: Used for acute treatment of migraine
Age: Patient is 18 years of age or older>=18 years
Prior acute therapy failure: History of therapeutic failure (after at least 3 migraine episodes and a minimum 30-day trial), contraindication, or intolerance to: (A) two of the listed triptans (examples: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan) AND (B) both Nurtec ODT and Ubrelvy (document names and dates tried)
Prescriber attestation: Prescriber attests to BOTH: (1) patient was informed Reyvow may cause significant CNS impairment and may impair ability to drive or operate machinery for 8 hours after each dose; and (2) if used with benzodiazepines or other CNS depressants, the prescriber has assessed increased risk for sedation and other cognitive/neuropsychiatric adverse events
Document counseling and assessment
Prophylactic therapy requirement or migraine frequency: Either patient is currently treated with one of the listed prophylactic therapies OR patient has >= 4 migraine days per month>=4 migraine days per month
Listed prophylactic agents include beta-blockers (e.g., atenolol, metoprolol, nadolol, propranolol, timolol), candesartan, CGRP antagonists/inhibitors (e.g., Aimovig, Ajovy, Emgality, Qulipta, Vyepti), divalproex sodium, SNRIs (duloxetine, venlafaxine), onabotulinumtoxinA, topiramate, and tricyclic antidepressants (amitriptyline, nortriptyline)

Reauthorization

Covered on reauthorization when ALL of the following are met:

Reauthorization: Documentation of positive clinical response to therapy

Authorization issued for 12 months

Ajovy (fremanezumab) is noted in the policy as typically excluded from coverage. Vyepti (eptinezumab) may be subject to additional benefit and coverage review requirements, which could affect coverage determinations or prior authorization processes. State mandates, federal requirements, the member’s specific benefit plan, and other utilization management programs may also affect coverage for these agents and related services. Providers should confirm plan-specific benefit rules and any required review workflows when considering CGRP-targeted preventive therapies referenced in the criteria.

Requests that involve onabotulinumtoxinA (Botox) for migraine prevention may be subject to additional benefit and coverage review requirements per the policy language and should be routed according to the member’s plan rules.

Use of Reyvow (lasmiditan) without meeting the documented prior therapy requirements or age/indication criteria will be considered not medically necessary. Specifically, coverage requires documentation that the patient is ≥18 years old, has the indicated diagnosis of acute migraine, and has a history of therapeutic failure, contraindication, or intolerance after at least three migraine episodes and a minimum 30-day trial to the required acute agents: trials of two listed triptans (examples provided in the policy) AND trials of both Nurtec ODT and Ubrelvy (names and dates must be documented).

Failure to provide the required documentation of prior trials, or absence of either the prophylactic therapy documentation or the alternative frequency criterion (i.e., being currently treated with a listed prophylactic agent or having ≥ 4 migraine days per month when applicable), may result in denial of coverage.

Provider Requirements and Prior Authorization Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for Reyvow (lasmiditan) for the acute treatment of migraine in adults. Submit documentation that confirms the indication and that the member meets ALL clinical requirements listed below before coverage will be approved.

Affected drug: Reyvow (lasmiditan)
Prior authorization required before first fill
Effective date: 2025-06-01

Step Therapy

Step Therapy Requirement

Step therapy requires documented therapeutic failure, intolerance, or contraindication to two different triptans AND documented trials of BOTH Nurtec ODT and Ubrelvy prior to approval of Reyvow.

Required trials: two different triptans (document name and dates tried). Eligible triptans include almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan.
Required trials: Nurtec ODT (rimegepant) — document name and date tried
Required trials: Ubrelvy (ubrogepant) — document name and date tried

Documentation Required

Required Documentation

Document the following at the time of prior authorization submission to demonstrate that the member meets criteria for Reyvow:

Patient age >= 18 years (include DOB or age)
Indication: acute treatment of migraine (with or without aura)
Names and dates of prior trials (or reason for lack of trial) for at least two different triptans
Names and dates of prior trials (or reason for lack of trial) for Nurtec ODT and for Ubrelvy
Documentation of therapeutic failure, intolerance, or contraindication for each required prior therapy tried
Prescriber attestation that patient was counseled about potential significant CNS impairment and advised not to drive or operate machinery for 8 hours after dosing
If concurrent CNS depressant use (e.g., benzodiazepines), documentation that the prescriber assessed increased risk for sedation and neuropsychiatric adverse events

Denial Risk

Missing Required Prior Therapies — Denial Risk

If documentation does not support trials of the required prior therapies (two triptans AND BOTH Nurtec ODT and Ubrelvy), the request is at high risk for denial. Include clear dates and reasons for discontinuation (failure, intolerance, or contraindication) to avoid denial.

Missing or incomplete trial documentation for any required agent may result in denial
Exceptions must be supported by medical justification (e.g., allergy, contraindication) with documentation
Denial risk applies when trials are not adequately documented or when reasons for not trying required agents are not provided

Background and Clinical Mechanism

Lasmiditan (Reyvow) is a selective serotonin 5-HT1F receptor agonist approved for the acute treatment of migraine with or without aura in adults. The policy requires that the medication be used for the acute treatment of migraine in patients who are at least 18 years of age.

Lasmiditan can cause significant central nervous system effects, including sedation and cognitive or neuropsychiatric adverse events. The prescriber must attest that the patient was counseled that Reyvow may impair the ability to drive or operate machinery for at least 8 hours after dosing and that the prescriber assessed the risk of increased CNS depression if Reyvow is used concomitantly with benzodiazepines or other CNS depressants.

Authorization for Reyvow per this policy is issued for 12 months, and guideline-recommended acute migraine management (NSAIDs, non-opioid analgesics, triptans, DHE) positions lasmiditan after failure or intolerance of the specified prior acute agents.

OpenPayer

Reyvow (lasmiditan) — Prior Authorization and Medical Necessity Criteria

Coverage and Medical Necessity Criteria

Coding and Related Criteria

Provider Requirements and Prior Authorization Actions

Background and Clinical Mechanism

Definitions and Safety Considerations