Qulipta (atogepant) — Medical Mutual

Initial criteria

• Patient has a migraine diagnosis according to the International Classification of Headache Disorders (ICHD-3); AND
• Patient age ≥ 18 years; AND
• Patient has ≥ 4 migraine headache days per month (prior to initiating a migraine-preventive medication); AND
• Patient has tried at least two standard prophylactic (preventive) pharmacologic therapies, each from a different pharmacologic class; AND
• Patient meets ONE of the following (a, b, or c):
• a. Patient has had inadequate efficacy to both of those standard prophylactic (preventive) pharmacologic therapies, according to the prescriber; OR
• b. Patient has experienced adverse event(s) severe enough to warrant discontinuation of both of those standard prophylactic (preventive) pharmacologic therapies, according to the prescriber; OR
• c. Patient has had inadequate efficacy to one standard prophylactic (preventive) pharmacologic therapy and has experienced adverse event(s) severe enough to warrant discontinuation of another standard prophylactic (preventive) pharmacologic therapy, according to the prescriber.

Reauthorization criteria

• Patient age > 18 years; AND
• If the patient is currently taking a CGRP antagonist, the patient has had a significant clinical benefit from the medication as determined by the prescriber.

Approval duration

initial: 3 months; reauth: 1 year