CurrentUnitedHealthcarePolicy N/A

Prior Authorization: Non-Preferred Drug and Quantity-Exception Requests for Migraine/Cluster Headache Therapies

This prior authorization/request form is used by providers to request coverage for non-preferred drugs or quantities exceeding standard limits (notably >12 per 30 days) for patients with migraine or cluster headache, affecting prescribers and patients seeking pharmacy coverage exceptions.

Policy Summary

PayerUnitedHealthcare

PolicyNon-Preferred Drug & Quantity-Exception Request Form for Migraine/Cluster Headache

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete the prior authorization form, document two failed preferred drugs or provide clinical justification, and sign the form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12standard quantity limit referenced

2preferred fails required

90preventative trial (days)

24concurrent-use exclusion (hrs)

Coverage Criteria

Criteria for Non-Preferred Drug Approval

Non-preferred drug request is permitted when ONE of the following is documented:

Non-preferred drug exception reasons: 1) Two preferred drugs have failed (list preferred drugs failed and provide reasons).

Provider must list the two preferred drugs that failed and indicate reason(s) (e.g., allergic reaction, drug–drug interaction) on the form.

Non-preferred drug exception reasons: 1a) Allergic reaction to preferred agent.

Describe reaction on the form.

Non-preferred drug exception reasons: 1b) Drug–drug interaction preventing use of preferred agent.

Describe interaction on the form.

Policy Summary

PayerUnitedHealthcare

PolicyNon-Preferred Drug & Quantity-Exception Request Form for Migraine/Cluster Headache

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete the prior authorization form, document two failed preferred drugs or provide clinical justification, and sign the form.

SourceLink

On This Page

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Criteria for Quantity Exception Approval

Quantity-exception (Exceeding 12 per 30 days) is considered when ALL of the following are addressed as applicable:

Quantity exception considerations: Confirm diagnosis of migraine or cluster headache.

Form includes a checkbox for diagnosis.

Quantity exception considerations: Document headache frequency (e.g., more than 6 moderate or severe headaches if asked).

Use form checkbox to indicate frequency.

Quantity exception considerations: Document history of NSAID therapy in the past year or document contraindication/allergy to NSAIDs.

Form asks if NSAID therapy occurred in past year and if there is a contraindication or allergy.

Quantity exception considerations: Document current use of a migraine preventative and any contraindication or adverse reaction to preventative medications.

Form requests listing of any preventative adverse reactions or contraindications.

Quantity exception considerations: Confirm lack of clinical benefit after at least a 90-day trial of preventative medications at the maximum tolerated dose.at least 90 days at maximum tolerated dose

Form includes a yes/no checkbox for a ≥90-day trial at maximum tolerated dose.

Quantity exception considerations: Confirm the patient does NOT have ischemic heart disease, peripheral vascular disease, cerebrovascular disease, ischemic bowel disease, or hemiplegic migraine.

Form includes a checkbox to identify these diagnoses; their presence is relevant to contraindication/exclusion.

Quantity exception considerations: Confirm the patient has not received a monoamine oxidase (MAO) inhibitor in the past 2 weeks.within past 2 weeks

Form includes a checkbox asking about MAO inhibitor use in past 2 weeks.

Quantity exception considerations: Ensure no concurrent use (or use within 24 hours) of ergotamine-containing/ergot-type medications or another 5‑HT1 agonist.within 24 hours

Form asks separate checkboxes for ergotamine-containing medications and other 5‑HT1 agonists.

Quantity exception considerations: Confirm the patient does not have uncontrolled hypertension or basilar migraine.

Form includes a checkbox for uncontrolled hypertension or basilar migraine.

Quantity exception considerations: Prescriber attests they have reviewed evidence-based recommendations on the treatment of migraine and signs the form.

Prescriber signature and date are mandatory on the form.

Patients with certain cardiovascular or cerebrovascular conditions and related contraindications must be identified on the request because these comorbidities affect the safety of acute migraine therapies. Specifically, the form flags history of ischemic heart disease, peripheral vascular disease, cerebrovascular disease, ischemic bowel disease, or hemiplegic migraine as clinically relevant exclusionary conditions for quantity-exception requests. The form also requires confirmation that the patient has not received an MAO inhibitor within the past 2 weeks and that there will be no concurrent use (or use within 24 hours) of an ergotamine-containing or other 5‑HT1 agonist.

Prescribers must also attest that the patient does not have uncontrolled hypertension or basilar migraine, which are listed as contraindications for certain acute migraine medications. These checks are required because concurrent or recent use of interacting agents and underlying ischemic or vascular disorders increase the risk of serious cardiovascular or cerebrovascular adverse events with some acute therapies.

Coding and Key Limits

Quantity limit — standard referenced limit

Standard quantity limit12 doses/units per 30 days

Policy referenceRequest for Exceeding Quantity Limit (Exceeding 12 per 30 days)

Applicable drug classAcute migraine/cluster headache medications (unspecified)

Preventative therapy trial duration — required duration at max tolerated dose

Required preventative trial durationAt least 90 days at maximum tolerated dose

Assessment item on formQuestion asks: 'Did the patient have no clinical benefit after at least a 90 day trial of preventative medications at the maximum tolerated dose?'

Role in quantity-exception requestsDocumented lack of benefit after this trial is required to consider exceeding the 12-per-30-day limit

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests for non-preferred drugs and for requests to exceed quantity limits. Use the required form to submit beneficiary, prescriber, and drug information and indicate length of therapy and requested quantity. Ensure the prescriber signature and date are included.

Applies to non-preferred product requests and quantity-exception requests (e.g., >12 per 30 days).
Use the completed form sections: Beneficiary Information, Prescriber Information, Drug Information, and the appropriate request subsection (Non-Preferred Drug or Exceeding Quantity Limit).
Prescriber signature is mandatory on the form.

Step Therapy

Step Therapy / Fail‑first Requirement

Step therapy / fail-first requirements must be documented for non-preferred drug requests unless a valid exception is met. Document failure of two preferred drugs, or provide a supported exception such as allergy, drug–drug interaction, clinical contraindication, or other medically appropriate rationale.

List the two preferred drugs that were tried and failed and indicate the clinical reason for failure (e.g., allergic reaction, unacceptable side effects, therapeutic failure).
Valid exceptions include: documented allergy to preferred agents, clinically significant drug–drug interaction, contraindication due to comorbidity, or other unique clinical circumstance supported by clinical information or literature.

Documentation Required

Required Documentation

Required documentation must accompany the prior authorization request. Provide complete beneficiary and prescriber details, full drug information, length of therapy, quantity requested, and supporting clinical documentation explaining failures or exceptions.

Beneficiary Information: name, ID number, DOB, gender.
Prescriber Information: NPI, contact name, phone, and extension.
Drug Information: drug name, strength, quantity per 30 days, and length of therapy (select duration or specify).
For non-preferred drug requests: completed section listing two preferred drugs tried and failed, dates/trial durations if available, and clinical details for failures or adverse events.
For quantity-exception requests: completed migraine/diagnosis checklist (questions 7–19) including history of headache frequency, prior preventative trials (90 days at max tolerated dose), contraindications, and concurrent medication concerns.
Include prescriber signature and date.

Denial Risk

Triggers for Denial

Requests may be denied if required documentation is missing or incomplete, or if the clinical rationale does not support the exception (step therapy failure or quantity justification). Ensure all requested fields and supporting clinical details are provided to avoid denial.

Missing documentation of two failed preferred drugs for non-preferred requests.
No clinical explanation or evidence for claimed allergy, interaction, contraindication, or therapeutic failure.
Incomplete drug information (drug name, strength, quantity, or length of therapy) or missing prescriber signature.
Insufficient justification for exceeding quantity limits (e.g., unanswered migraine-specific checklist items, no documentation of preventive therapy trial or contraindication).

Preferred drug (list)	Reason(s) failed
Preferred drug 1: ________________________________________
Reason(s): select/describe (e.g., Allergic reaction; Drug–drug interaction; Unacceptable side effect; Therapeutic failure; Contraindication). Use form checkboxes and provide details: _______________________
Preferred drug 2: ________________________________________
Reason(s): select/describe (e.g., Allergic reaction; Drug–drug interaction; Unacceptable side effect; Therapeutic failure; Contraindication). Use form checkboxes and provide details: _______________________

Definitions

Exceeding 12 per 30 days — definition of quantity limit exceedance

Definition'Exceeding 12 per 30 days' refers to requests for quantities greater than the standard 12 doses/units within a 30-day period

Form triggerHandled via the 'Request for Exceeding Quantity Limit' section of the form

Considerations requiredPrescriber must confirm diagnosis, headache frequency, NSAID history/contraindication, preventative trial results, and safety exclusions (e.g., ischemic vascular disease, recent MAOI, concurrent ergot/5-HT1 agonist use, uncontrolled hypertension, basilar migraine)

Failed two preferred drug(s) — definition of treatment failure for preferred drugs

Definition of failureFailure of two preferred drugs — prescriber must list the two preferred agents that failed and provide reasons (e.g., allergic reaction, drug–drug interaction, unacceptable side effect, or therapeutic failure)

Required documentationForm includes fields to list preferred drugs failed and to indicate allergic reaction or drug–drug interaction details

Acceptable reasonsAllergic reaction, drug–drug interaction, previous unacceptable side effect, therapeutic failure, clinical contraindication, comorbidity, or unique patient circumstance

Background

This request form is used to obtain prior authorization for non-preferred acute migraine or cluster headache therapies and to request a quantity exception when a prescriber seeks > 12 doses per 30 days. It focuses on acute treatment needs and collects clinical information to support either a non-preferred drug exception (documentation of failed preferred therapies or other clinically justified reasons) or a quantity-exception request for frequent/severe headache burden.

For quantity-exception requests the form documents diagnosis of migraine or cluster headache, headache frequency/severity, prior NSAID use or contraindication, current and prior preventive therapy (including whether there was no clinical benefit after at least a 90-day trial of preventative medications at the maximum tolerated dose), and specific safety checks (ischemic vascular disease, recent MAO inhibitor use, concurrent ergot/5‑HT1 agonist use within 24 hours, uncontrolled hypertension, basilar migraine). The prescriber must review evidence-based recommendations and sign the form to attest to the completed clinical assessment.

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