Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Headaches.
Treatment:  Formulary Exception for Nurtec ODT (oral disintegrating tablet) tablets.

The insurer denied Formulary Exception for Nurtec ODT (oral disintegrating tablet) tablets.  The denial is upheld.

This case involves an adult patient who was seen for tinnitus, headaches, and sleep issues. Comorbidities included anxiety, hyperlipidemia, hypothyroidism, and vitamin D deficiency. The patient endorsed severe frontal headaches and tinnitus of both ears. The patient stated that headaches have been ongoing for more than 2 years and reported more than 5 days per month of severe headaches. The patient had possible auras before the headaches and reported some eye/vision changes prior to onset. The patient used Excedrin Migraine with good results and reported a history of allergic rhinitis. The patient was started on Allegra-D for 7 to 10 days to treat the sinus headaches. The patient was seen most recently for headaches and tinnitus. The patient stated that symptoms had significantly increased in severity and frequency in the past 6 months and reported at least 4 headaches a week totaling approximately 20 a month. The patient endorsed increasing stress at work and at home and was prescribed loratadine pseudoephedrine to treat sinus congestion, which did not improve headaches. The patient's headaches were 4-8 on a pain scale of 1 to 10 in severity. The pain was described as pulsating, dull, sharp, all different types, and different each time. The headaches are located behind the eyes, the back of the head, across the forehead, and occasionally on one side. The patient reported occasional photophobia and phonophobia with occasional nausea. The patient also endorsed floaters and blurry vision along with diplopia, constant tinnitus, and vertigo/dizziness. The treatment plan included referring the patient to ear/nose/throat specialist and neurology. The treatment plan included consultation/referral, laboratory testing, diagnostic imaging, along with orders for the patient to use Nurtec ODT (oral disintegrating tablet) tablet. The patient received a notice of adverse determination regarding Nurtec ODT. The notification stated that coverage was denied as the plan, per criteria, was not met. There was no record of the patient trying and failing formulary alternatives to include Ubrelvy and Aimovig. 

The formulary drug is not likely to cause the patient an adverse reaction.

There is no confirmation that the requested drug may be more effective than the formulary drugs until the patient tries Ubrelvy or Aimovig, given that either of these medications may be beneficial in treating the condition.

The Food and Drug Administration (FDA) states that Nurtec ODT is indicated for the acute treatment of migraine with or without aura in adults and preventative treatment of episodic migraine in adults. The documentation provided for the review did not verify that the patient was suffering from migraine headaches. The information indicated that the patient was suffering from sinus headaches associated with allergies. The information did not support that the patient had tried other formulary drugs to include Ubrelvy and Aimovig before the physician submitted a request for Nurtec ODT. The patient also endorsed benefit from the use of Excedrin Migraine. The evidence did not support that the patient cannot use formulary alternatives nor that Nurtec ODT would be more effective than other formulary drugs. The Formulary Exception request for Nurtec ODT is not approved.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The not formulary drug is not expected to be more effective that the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Nurtec ODT (oral disintegrating tablet) tablets to treat headaches is upheld.