Ubrelvy Prior Authorization with Quantity Limit Criteria - Medicare Part D

Prior Authorization Criteria for Approval

Initial Evaluation

Ubrelvy will be approved when ALL of the following are met:

1. The patient has a diagnosis of migraine
   AND

2. The requested medication is being used for the treatment of acute migraine with or without aura
   AND

3. ONE of the following:

   1. The patient has tried and had an inadequate response to a triptan (e.g., sumatriptan, rizatriptan) medication
      OR
   2. The patient has an intolerance or hypersensitivity to a triptan
      OR
   3. The patient has an FDA labeled contraindication to a triptan
      AND

4. The patient will NOT be using the requested medication in combination with another acute migraine medication (e.g., triptan, 5HT-1F, ergotamine, acute CGRP)
   AND

5. ONE of the following:

   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR

   2. ALL of the following:

      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months

Renewal Evaluation

Ubrelvy will be approved when ALL of the following are met:

1. The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria
   AND

2. The patient has a diagnosis of migraine
   AND

3. The requested medication is being used for the treatment of acute migraine with or without aura
   AND

4. The patient has had clinical benefit with the requested medication
   AND

5. The patient will NOT be using the requested medication in combination with another acute migraine medication (e.g., triptan, 5HT-1F, ergotamine, acute CGRP)
   AND

6. ONE of the following:

   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR

   2. ALL of the following:

      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months