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Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Acute

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Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Acute Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists (Acute Treatment) Clinical Information Included in this Document Nurtec (Rimegepant) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules Logic diagram: a visual depiction of the clinical criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section. Ubrelvy (Ubrogepant) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules Logic diagram: a visual depiction of the clinical criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section. October 28, 2020 Copyright © 2011-2020 Health Information Designs, LLC 1 Revision Notes Initial publication, with changes recommended by the DUR Board included October 28, 2020 Copyright © 2011-2020 Health Information Designs, LLC 2 Texas Prior Authorization Program Clinical Criteria CGRP Antagonists (Acute) Nurtec (Rimegepant) Drugs Requiring Prior Authorization The listed GCNS may not be an indication of TX Medicaid Formulary coverage. To learn the current formulary coverage, visit TxVendorDrug.com/formulary/formulary-search. Drugs Requiring Prior Authorization Label Name GCN NURTEC ODT 75 MG TABLET 47762 October 28, 2020 Copyright © 2011-2020 Health Information Designs, LLC 3 Texas Prior Authorization Program Clinical Criteria CGRP Antagonists (Acute) Nurtec (Rimegepant) Clinical Criteria Logic 1. Is the medication being prescribed by, or in consultation with, a neurologist, pain specialist or headache specialist; or has the client been seen in the emergency room for treatment of migraine; or has the client had imaging tests for migraine? [Manual] [ ] Yes (Go to #2) [ ] No (Deny) 2. Is the client greater than or equal to (≥) 18 years of age? [ ] Yes (Go to #3) [ ] No (Deny) 3. Does the client have a diagnosis of migraine headache in the last 730 days? [ ] Yes (Go to #4) [ ] No (Deny) 4. Does the client have an approved prior authorization for rimegepant or ubrogepant in the last 365 days? [ ] Yes (Go to #6) [ ] No (Go to #5) 5. Has the client tried and failed therapy with at least 2 different triptans, or does the client have a contraindication to triptan therapy? [ ] Yes (Go to #6) [ ] No (Deny) 6. Does the client have a diagnosis of severe hepatic impairment in the last 365 days? [ ] Yes (Deny) [ ] No (Go to #7) 7. Does the client have a claim for a contraindicated drug in the last 30 days? [ ] Yes (Deny) [ ] No (Go to #8) 8. Is the requested quantity greater than 16 tablets in 30 days? [ ] Yes (Deny) [ ] No (Approve – 90 days) October 28, 2020 Copyright © 2011-2020 Health Information Designs, LLC 4 Texas Prior Authorization Program Clinical Criteria CGRP Antagonists (Acute) Nurtec (Rimegepant) Clinical Criteria Logic Diagram Step 1 Is the medication being Step 2 Step 3 prescribed by or in consultation with a Yes Is the client ≥ 18 years Yes Does the client have a No specialist; or has the client of age? diagnosis of migraine Deny Request been seen in ER for headache in the last migraine; or had imaging 730 days? tests for migraine? [Manual] No Yes No Step 4 Does the client have an Deny Request approved prior Yes authorization for Go to Step 6 Deny Request rimegepant or ubrogepant in the last 365 days? No Step 5 Approve Request Has the client tried and failed No (90 days) therapy with at least 2 different Deny Request triptans or is there a contraindication to triptan therapy? No Yes Step 7 Step 6 Step 8 Does the client have a Does the client have a Is the requested No claim for a No diagnosis of severe quantity > 16 tablets in contraindicated drug in hepatic impairment in 30 days? the last 30 days? the last 365 days? Yes Yes Yes Deny Request Deny Request Deny Request October 28, 2020 Copyright © 2011-2020 Health Information Designs, LLC 5 Texas Prior Authorization Program Clinical Criteria CGRP Antagonists (Acute) Ubrelvy (Ubrogepant) Drugs Requiring Prior Authorization The listed GCNS may not be an indication of TX Medicaid Formulary coverage. To learn the current formulary coverage, visit TxVendorDrug.com/formulary/formulary-search. Drugs Requiring Prior Authorization Label Name GCN UBRELVY 100 MG TABLET 47478 UBRELVY 50 MG TABLET 47477 October 28, 2020 Copyright © 2011-2020 Health Information Designs, LLC 6 Texas Prior Authorization Program Clinical Criteria CGRP Antagonists (Acute) Ubrelvy (Ubrogepant) Clinical Criteria Logic 1. Is the medication being prescribed by, or in consultation with, a neurologist, pain specialist or headache specialist; or has the client been seen in the emergency room for treatment of migraine; or has the client had imaging tests for migraine? [Manual] [ ] Yes (Go to #2) [ ] No (Deny) 2. Is the client greater than or equal to (≥) 18 years of age? [ ] Yes (Go to #3) [ ] No (Deny) 3. Does the client have a diagnosis of migraine headache in the last 730 days? [ ] Yes (Go to #4) [ ] No (Deny) 4. Does the client have an approved prior authorization for rimegepant or ubrogepant in the last 365 days? [ ] Yes (Go to #6) [ ] No (Go to #5) 5. Has the client tried and failed therapy with at least 2 different triptans, or does the client have a contraindication to triptan therapy? [ ] Yes (Go to #6) [ ] No (Deny) 6. Does the client have a diagnosis of end stage renal disease (ESRD) in the last 365 days? [ ] Yes (Deny) [ ] No (Go to #7) 7. Does the client have a claim for a strong CYP3A4 inhibitor or inducer in the last 30 days? [ ] Yes (Deny) [ ] No (Go to #8) 8. Is the requested quantity greater than 20 tablets in 30 days? [ ] Yes (Deny) [ ] No (Approve – 90 days) October 28, 2020 Copyright © 2011-2020 Health Information Designs, LLC 7 Texas Prior Authorization Program Clinical Criteria CGRP Antagonists (Acute) Ubrelvy (Ubrogepant) Clinical Criteria Logic Diagram Step 1 Is the medication being Step 2 Step 3 prescribed by or in consultation with a Yes Is the client ≥ 18 years Yes Does the client have a No specialist; or has the client of age? diagnosis of migraine Deny Request been seen in ER for headache in the last migraine; or had imaging 730 days? tests for migraine? [Manual] No Yes No Step 4 Does the client have an Deny Request approved prior Yes authorization for Go to Step 6 Deny Request rimegepant or ubrogepant in the last 365 days? No Step 5 Has the client tried and failed No therapy with at least 2 different Deny Request triptans or is there a contraindication to triptan therapy? Yes Step 6 Does the client have a Yes diagnosis of ESRD in Deny Request the last 365 days? No Step 7 Step 8 Does the client have a No Is the requested No claim for a strong quantity > 20 tablets in Approve Request CYP3A4 inhibitor or 30 days? (90 days) inducer in the last 30 days? Yes Yes Deny Request Deny Request October 28, 2020 Copyright © 2011-2020 Health Information Designs, LLC 8 Texas Prior Authorization Program Clinical Criteria CGRP Antagonists (Acute) CGRP Antagonists (Acute) Clinical Criteria Supporting Tables Step 3 (diagnosis of migraine headache) Required diagnosis: 1 Look back timeframe: 730 days ICD-10 Code Description MIGRAINE WITHOUT AURA, NOT INTRACTABLE WITH STATUS G43001 MIGRAINOSUS MIGRAINE WITHOUT AURA, NOT INTRACTABLE WITHOUT STATUS G43009 MIGRAINOSUS MIGRAINE WITHOUT AURA, INTRACTABLE WITH STATUS G43011 MIGRAINOSUS MIGRAINE WITHOUT AURA, INTRACTABLE WITHOUT STATUS G43019 MIGRAINOSUS MIGRAINE WITH AURA, NOT INTRACTABLE WITH STATUS G43101 MIGRAINOSUS MIGRAINE WITH AURA, NOT INTRACTABLE WITHOUT STATUS G43109 MIGRAINOSUS G43111 MIGRAINE WITH AURA, INTRACTABLE WITH STATUS MIGRAINOSUS MIGRAINE WITH AURA, INTRACTABLE WITHOUT STATUS G43119 MIGRAINOSUS HEMIPLEGIC MIGRAINE, NOT INTRACTABLE WITH STATUS G43401 MIGRAINOSUS HEMIPLEGIC MIGRAINE, NOT INTRACTABLE WITHOUT STATUS G43409 MIGRAINOSUS G43411 HEMIPLEGIC MIGRAINE, INTRACTABLE WITH STATUS MIGRAINOSUS HEMIPLEGIC MIGRAINE, INTRACTABLE WITHOUT STATUS G43419 MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION WITH G43501 STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION G43509 WITHOUT STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, G43511 INTRACTABLE WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, G43519 INTRACTABLE WITHOUT STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, NOT G43601 INTRACTABLE WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, NOT G43609 INTRACTABLE WITHOUT STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, G43611 INTRACTABLE WITH STATUS MIGRAINOSUS PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, G43619 INTRACTABLE WITHOUT STATUS MIGRAINOSUS October 28, 2020 Copyright © 2011-2020 Health
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