Diagnosis: Chronic migraine without aura, not intractable
Treatment: Formulary exception for Ubrelvy 100mg tablets
The insurer denied: Formulary exception for Ubrelvy 100mg tablets
The denial is upheld

The patient is an adult female with migraine headache disorder. She has tried and failed sumatriptan and eletriptan for abortive therapy. The provider is requesting Ubrelvy. The requested medication was denied coverage by the health plan, as she has not tried and failed three formulary medications for her condition, and she does not have a contraindication to using the preferred agents. The denial is being appealed.

The health plan should not cover the Formulary exception for Ubrelvy 100mg tablets.

There is no documented reason the patient cannot be treated with the preferred agents. Previous side effects from other medications do not preclude the use of the preferred agents. She does not have a contraindication to using any of the preferred agents. The preferred medications are FDA (United States Food and Drug Administration)-approved for the acute treatment of migraine headaches and are considered first-line, standard-of-care, abortive agents (Tepper, 2019). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Ubrelvy relative to the preferred medications.