To analyze the prior authorization criteria for CGRP-modulating medications and identify common themes and discrepancies between insurers.

Since 2018, a multitude of CGRP-modulating medications have been approved for the treatment of migraine. These medications are the first migraine-specific medications since triptans, which were FDA-approved in 1991. Though these therapeutic options are now available, prior authorization remains an increasingly common hurdle hindering patient access to effective treatment.

Major commercial and Medicaid healthcare insurers were identified using the South Carolina Department of Insurance (SCDOI) and South Carolina Department of Health and Human Services (SCDHHS) websites. Prior authorization policies for all FDA-approved CGRP-modulating medications to date for treating migraine were obtained either from insurers’ websites or by contacting company representatives by phone. Policy criteria were tabulated for analysis.

Ten commercial insurers were identified, some of which also included Medicaid (n=5). All insurers carried at least one anti-CGRP receptor monoclonal antibody (mAb) for preventive therapy and at least one CGRP-antagonist (gepant) for acute treatment. Insurers required a trial of at least one (n=3) or two (n=7) triptan medications or documentation of contraindication or adverse effect for acute medications. They required a trial of at least one oral medication from one (n=2), two (n=7), or three (n=1) different medication classes for preventive medications. Some policies included additional details, such as necessitating further review for concurrent use of Botox with a CGRP-modulating preventive medication (n=5) and prohibition of concurrent use of mAbs and gepants for the same indication (n=7) or in general (n=2).

Despite availability of clear FDA guidelines and professional consensus statements, prior authorization policies for migraine-specific medications are highly variable. Without knowledge of these details, initiation of effective patient treatment will inevitably be delayed.