Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraines
Treatment: Ubrelvy 100 mg (milligram) tablets
The insurer denied coverage for Ubrelvy 100 mg (milligram) tablets
The denial is overturned

The treating provider has diagnosed the patient with chronic migraines, anxiety, and depression. The patient has tried and failed Excedrin, ibuprofen, naproxen, BC powder (aspirin 845 mg(milligrams) caffeine 65 mg), sumatriptan, nabumetone, Nurtec, naratriptan (ineffective, sedation) and frovatriptan (ineffective). The treating provider is requesting approval for therapy with Ubrelvy.

The patient was seen by the nurse practitioner (NP) for follow-up regarding migraines. The NP noted that the patient continued to be on Topiramate, which was well tolerated, and the patient reported one-to-two headache days per week. The NP stated the patient was using Ubrelvy for acute treatment of migraines and was needing up to eight tablets a month. In the assessment, the NP noted the chronic migraine. The plan was to continue with topiramate for migraine prevention, and use Naratriptan for abortive medication, and if ineffective, to use Eletriptan, and if that is ineffective, the plan was to appeal for the Ubrelvy. 

An appeal letter stated the patient was on Topiramate for migraine prevention, which has been a very effective acute medication, and was well tolerated. It was noted, the patient failed Sumatriptan, naratriptan, Frovatriptan, and Nurtec.

However, the patient has already tried many of the medications on the formulary list with no effect, including three within the same class (frovatriptan, naratriptan, and sumatriptan); selective serotonin receptor agonists.    

The formulary drugs, three within a class have been ineffective for this patient. The patient has tried and failed frovatriptan, naratriptan, and sumatriptan; selective serotonin receptor agonists. The patient has also failed a CGRP (calcitonin gene related peptide) and an NSAID (non-steroidal anti-inflammatory drug).     

Ubrelvy has been documented to be effective for this patient's migraines, when formulary alternatives, three within a class were ineffective.
"Ubrogepant is an oral, small-molecule calcitonin generelated peptide receptor antagonist for acute migraine treatment." (Dodick, et al., 2019).

"Conclusions and relevance: Among adults with migraine, acute treatment with ubrogepant compared with placebo led to significantly greater rates of pain freedom at 2 hours with 50-mg and 25-mg doses, and absence of the most bothersome migraine-associated symptom at 2 hours only with the 50-mg dose. Further research is needed to assess the effectiveness of ubrogepant against other acute treatments for migraine and to evaluate the long-term safety of ubrogepant among unselected patient populations." (Lipton, et al., 2019).

"Conclusions and relevance: There are several acute treatments for migraine, with varying strength of supporting evidence. Use of triptans, nonsteroidal anti-inflammatory drugs, acetaminophen, dihydroergotamine, calcitonin gene-related peptide antagonists, lasmiditan, and some nonpharmacologic treatments was associated with improved pain and function. The evidence for many other interventions, including opioids, was limited." (VanderPluym, et al., 2021).                                                       

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Formulary Exception for Ubrelvy 100 mg (milligram) tablets is overturned.