Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraine
Treatment: Formulary Exception for Nurtec 75 milligrams (mg) tablets
The insurer denied coverage for formulary exception for Nurtec 75 mg tablets.
The denial is overturned.

This case involves an adult patient with a history of migraines. The patient's symptoms were described as throbbing, pounding, bitemporal, and associated with dizziness, lightheadedness, blurred vision, and light and sound sensitivity with an occasional feeling of nausea. The patient takes ibuprofen, which helped, but headaches would persist for several hours throughout the day. Symptoms tended to worsen with activity. The physician was recommending Nurtec 75 milligrams (mg) to be taken 1 tablet daily as needed for headaches. The patient received a notice of final adverse determination regarding Nurtec oral disintegrating tablet (ODT) 75 mg for the treatment of chronic migraine without aura, not intractable, without status migrainosus. An appeal response was submitted stating that the patient has a history of chronic migraines and has a contraindication to triptan therapy due to a medical history significant for vasculitis. The physician reviewed and recognized guidelines for preferred formulary medications. It was understood that the reason for denial was that the patient must try and fail triptan/dihydroergotamine therapy, ibuprofen, or Aimovig, Emgality, or Ajovy. The physician stated that the use of triptans and dihydroergotamine are contraindicated because of the patient's vasculitis, making both inappropriate options with reports that triptan use would most likely worsen or exacerbate the patient's condition. Aimovig, Emgality, and Ajovy are inappropriate options for the patient as they are for prophylaxis for migraines and the patient is already on prophylactic therapy with gabapentin. The patient has tried and failed ibuprofen therapy and continues to experience symptoms. The physician explained that Nurtec ODT (Rimegepant) is to be used for acute treatment of migraine and is the most appropriate option for the patient. 

The Food and Drug Administration (FDA) states that Nurtec is indicated for the acute treatment of migraine with or without aura in adults and preventative treatment of episodic migraine in adults. The information provided for the review indicated that the proposed formulary drugs are likely to cause the patient an adverse reaction given the history of vasculitis. Additionally, Aimovig, Emgality, and Ajovy are for prophylaxis for migraines and the patient is already on prophylactic therapy with gabapentin. Formulary drugs have not been trialed given the patient's history of vasculitis and the indication that the patient did not require another prophylactic medication. It was therefore determined that the requested drug would be more effective than the formulary drugs given that the patient needed a medication to treat acute migraine due to the current regimen no longer being effective given the ongoing symptoms. 

The formulary drugs are expected to cause adverse effects. The formulary drugs were not tried, and the patient did have an adverse reaction or contraindication. The formulary drug is expected to be ineffective. The non-formulary drug is expected to be more effective than the formulary alternatives.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for formulary exception for Nurtec 75 mg tablets is substantiated.