CommercialPrior AuthMedium impact
Nurtec™ ODT (rimegepant) (Revised)
Humana·Neurology, General Practice, Pain Management +2 more·Commercial
Effective date
Feb 28, 2024
We identified it
Jun 25, 2026
Summary
This is a 1-day-old policy revision for Nurtec ODT (rimegepant) that establishes prior authorization requirements for both acute migraine treatment and migraine prevention in commercial plans. Billing teams must verify that members meet specific clinical criteria (previous treatment failure with triptans for acute use, or inadequate response to oral preventives for prevention use) before claims will be approved.
Action Required
By March 15, 2025: Billing and prior authorization teams must implement the following: (1) All Nurtec ODT (rimegepant) claims for Humana commercial members now require prior authorization; (2) For ACUTE MIGRAINE claims: Verify member has documented previous treatment, intolerance, or contraindication to ONE of: naratriptan, rizatriptan, or sumatriptan before submitting; (3) For MIGRAINE PREVENTION claims: Verify member has <50% reduction in migraine days per month after at least 2 months of prior treatment with one of: Divalproex, Topiramate, Metoprolol, Propranolol, or Timolol; (4) Update claim submission templates and prior auth request forms to include these clinical criteria; (5) Train front-desk and billing staff to collect this documentation from providers before processing; (6) Update billing software to flag any Nurtec ODT claims lacking required prior authorization. Claims submitted without meeting these criteria or without prior auth approval will be denied. Refer to http://apps.humana.com/tad/tad_new/home.aspx to verify current policy status before each submission.