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L.5.01.566
Nurtec ODT (rimegepant)
Qulipta (atogepant)
Ubrelvy (ubrogepant)
Zavzpret (zavegepant)
Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
Calcitonin gene-related peptide (CGRP) is a protein that carries pain signals along nerves involved in causing headache pain associated with migraine. Gepants are small-molecule oral or intranasal CGRP antagonists that block CGRP from attaching to its receptor and initiating pain signals.
Nurtec ODT (rimegepant) is indicated for the acute treatment of migraine with or without aura in adults and for the preventive treatment of episodic migraine in adults.
Qulipta (atogepant) is indicated for the preventive treatment of migraines in adults.
Ubrelvy (ubrogepant) is indicated for the acute treatment of migraine with or without aura in adults.
Zavzpret (zavegepant) is indicated for the acute treatment of migraine with or without aura in adults.
Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), and Zavzpret (zavegepant) are considered not medically necessary for the acute treatment and prevention of migraine as there are other alternatives covered by the Plan.
State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
appropriate with regard to standards of good medical practice; and
not solely for the convenience of the Member, his or her Provider; and
the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
BCBSMS may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.
Medication failure is defined as disease progression despite maximally tolerated dose (≥3 months use) as appropriate for disease state being treated. Experience of common side effects of medication will not be considered medication failure for the purpose of this review.
BCBSMS determines individual medication trial and adherence by a review of pharmacy claims data over the preceding twelve months. Additional information may be requested on a case-by-case basis to allow for proper review. If individual is new to BCBSMS and pharmacy records are needed to confirm medication trials and adherence, it is the responsibility of the individual and/or requesting provider to obtain said records and to submit them to BCBSMS upon request. Medical records from the provider that list previously prescribed medications will not be sufficient to show medication trials or adherence.
08/06/2020: New policy added. Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.
07/13/2021: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Policy statement unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders." Removed definition of investigative. Added information regarding BCBSMS request for medical records. Sources updated.
02/01/2023: Policy Exceptions updated to add the following: State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
10/01/2024: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy description revised regarding indications for Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), and Zavzpret (zavegepant). Policy updated to state that Nurtec ODT (rimegepant), Qulipta (atogepant), Ubrelvy (ubrogepant), and Zavzpret (zavegepant) are considered not medically necessary for the acute treatment and prevention of migraine as there are other alternatives covered by the Plan. It previously stated: Nurtec ODT (rimegepant) and Ubrelvy (ubrogepant) are considered not medically necessary for the acute treatment of migraine with or without aura in adults as there are other alternatives covered by the Plan. Sources updated.
09/09/2025: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy description updated regarding indications for Nurtec ODT (rimegepant), Ubrelvy (ubrogepant), and Zavzpret (zavegepant). Policy statement unchanged. Sources updated.
Ailani J, Burch RC, Robbins MS; the Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021; 61: 1021–1039. https://doi.org/10.1111/head.14153
Nurtec ODT prescribing information. Pfizer Laboratories Div Pfizer, Inc. April 2025. Last accessed June 2025.
Ubrelvy prescribing information. Allergan, Inc. March 2025. Last accessed June 2025.
Qulipta prescribing information. AbbVie, Inc. March 2025. Last accessed June 2025.
Zavzpret prescribing information. Pfizer Laboratories Div Pfizer Inc. April 2025. Last accessed June 2025.
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