Policy Pulse
Q1 2026 — Published March 26, 2026
What changed in headache disorder payer policy this quarter.
Plain-language briefing for clinic managers, PCPs, and practice admins. 330 verified changes across 51 jurisdictions from the Q1 2026 annual formulary reset.
Clinical Briefing
Written for a clinical coordinator to brief their team in 5 minutes.
The single biggest win this quarter: Zavzpret is finally on formulary.
Cigna became the first major national commercial payer to add Zavzpret (zavegepant nasal spray) at Tier 2 Preferred status, effective May 1, 2026. This matters for patients who cannot tolerate oral gepants or need faster onset — Zavzpret had been largely inaccessible without PA. UHC has also added it to PA criteria alongside Ubrelvy, and over 80 payers nationally added formulary entries this quarter. When submitting PA for Zavzpret starting May 1, document why oral route is contraindicated or insufficient.
The Medicare Botox landscape just changed significantly. Noridian MAC updated Botox LCD L35172 across all 9 of its jurisdictions (AZ, CA, CO, HI, ID, NV, OR, SD, UT, WA, WY), effective February 22, 2026. The new requirement: objective clinical scale documentation — MIDAS, HIT-6, or equivalent — is now mandatory for OPD and ASC prior authorization. If you are in a Noridian jurisdiction and your Botox PA workflow doesn't automatically pull a MIDAS or HIT-6 score, update your intake forms now. WPS, NGS, and Palmetto MACs added similar ASC PA demonstration requirements in their regions (IA, KS, MO, NE, MN, and others). This is not a denial — it's a documentation requirement — but missing it will generate preventable rejections.
Two policy trends demand attention for chronic management: First, concurrent CGRP mAb + gepant is now explicitly prohibited by both UHC and Cigna, and Molina's new “Therapeutic Duplication Edit” will reject concurrent claims at the PBM level automatically. If patients are on both, a proactive switch or prior authorization exception is needed. Second, and worth celebrating: OptumRx eliminated reauthorization for all CGRP migraine drugs nationally — once a patient is approved, reauth is every 2 years, not annually. That is a significant administrative reduction for practices managing chronic patients on CGRPs.
Action Items for Your Clinic
- Noridian jurisdictions (AZ, CA, CO, HI, ID, NV, OR, SD, UT, WA, WY): Add MIDAS/HIT-6 to Botox PA checklist — required as of Feb 22, 2026.
- Zavzpret PAs: Starting May 1, document oral gepant intolerance or need for faster onset. Cigna Tier 2 Preferred reduces patient cost significantly.
- Concurrent CGRP + gepant patients: Audit your panel. UHC/Cigna/Molina will deny concurrent claims. Prepare clinical exception letters or transition plans.
- OptumRx / UHC patients: Remove annual CGRP reauth reminders from workflow — reauth is now every 2 years.
- Georgia practices: SB 315 is law as of Jan 1, 2026. Payers must respond to PA requests within 72 hours.
- Colorado practices: Gold Card exemption now applies to all commercial payers statewide.
Formulary Changes
221 formulary tier map updates applied. Red = adverse / cost-increasing. Green = favorable / access-expanding.
| Drug | Class | Payer | Change | States / Scope | Effective | PA | Impact |
|---|---|---|---|---|---|---|---|
| Zavzpret (zavegepant) | Gepants — Acute | Cigna (Commercial) | Added — Tier 2 Preferred First major commercial payer to add Zavzpret at preferred status. PA required. | 13 states (AR, AZ, CO, DE, GA, NC, NH, TN, WV + others) | May 1, 2026 | PA REQ | Favorable |
| Zavzpret (zavegepant) | Gepants — Acute | UHC (Commercial) | Added to PA criteria Added alongside Ubrelvy in PA criteria. 80+ payers added Zavzpret formulary entries nationally. | National | Q1 2026 | PA REQ | Favorable |
| Qulipta (atogepant) | Gepants — Preventive | Medicaid PDL | Added — Preferred Status Oral preventive gepant access expanded for Medicaid populations in three states. | MS, MT, NY | Jan 1, 2026 | PA REQ | Favorable |
| CGRP mAbs (SC) | CGRP mAbs — Subcutaneous | Medi-Cal Rx (CA Medicaid) | Lookback period shortened: 450 → 100 days Shorter step therapy lookback means faster CGRP access for CA Medicaid patients. | California | Jan 1, 2026 | PA REQ | Favorable |
| Vyepti (eptinezumab) | CGRP mAbs — IV | Aetna Medicare Advantage | Step therapy tightened More stringent step therapy requirements for IV CGRP access in Aetna MA plans. | 12+ states | Jan 1, 2026 | PA REQ | Adverse |
| Ajovy (fremanezumab) | CGRP mAbs — Subcutaneous | Cigna (Individual & Family Plans) | Preferred product step criteria removed Smoother path to injectable CGRP for Cigna IFP members — no required in-class sequencing. | Multiple states | Feb 1, 2026 | PA REQ | Favorable |
| Botox (onabotulinumtoxinA) | Neurotoxin | Noridian MAC (Part B) | LCD L35172 updated — objective scale documentation required Mandatory objective clinical scale (MIDAS, HIT-6, or equivalent) now required for OPD/ASC PA submission. | AZ, CA, CO, HI, ID, NV, OR, SD, UT, WA, WY (9 jurisdictions) | Feb 22, 2026 | PA REQ | Adverse |
| Botox (onabotulinumtoxinA) | Neurotoxin | WPS / NGS / Palmetto MAC (Part B) | ASC PA demonstration requirement added New prior authorization demonstration required for ambulatory surgical center Botox claims. | IA, KS, MO, NE (WPS); MN (NGS); Multiple (Palmetto) | Jan–Feb 2026 | PA REQ | Adverse |
Showing 8 highest-clinical-impact changes. 221 formulary updates applied in total. Data confidence: Cross-validated and PBM-inferred sources only.
Step Therapy Updates
New requirements, relaxations, and within-class sequencing changes. 109 policy updates applied.
OptumRx eliminated reauthorization requirements nationally. Initial PA still required, but approved patients on chronic therapy no longer face annual reauth. CGRP-specific: reauth interval extended to every 2 years.
Cigna Individual & Family Plans no longer require patients to try a preferred CGRP first before accessing Ajovy. Reduces in-class sequencing burden.
Updated step therapy requirements for subcutaneous CGRP mAbs in the Indiana Medicaid fee-for-service program.
Step therapy requirements updated for CGRP mAb coverage under KY Medicaid Aetna MCO.
More stringent step therapy requirements introduced for IV CGRP access. Affected states include TX, FL, OH, PA, MI, and others. Verify state-specific criteria before PA submission.
Molina implemented a system-wide "Therapeutic Duplication Edit" for CGRP medications effective January 2026. Claims for concurrent CGRP mAb + gepant will be rejected at the PBM level.
Both UHC and Cigna updated PA criteria to explicitly prohibit concurrent use of a CGRP monoclonal antibody with a gepant (acute or preventive). This closes a common polypharmacy pathway. Document clinical rationale clearly if seeking exception.
Molina, UHC, and Cigna have now all implemented explicit restrictions on concurrent CGRP mAb + gepant use (whether gepant is acute or preventive). This is a dominant payer trend — expect more plans to follow. No payer has approved the combination as a covered regimen. Patients currently on both drugs should be proactively counseled and transition plans documented before renewal.
State-by-State
Only states with confirmed changes shown. Sorted by region.
State-by-state filtering coming soon. All states with changes shown below.
West
- Medi-Cal Rx: CGRP lookback period shortened 450 → 100 days (Jan 1, 2026)
- Noridian MAC: Botox LCD L35172 updated — objective scale documentation required (Feb 22, 2026)
- Cigna: Zavzpret added Tier 2 Preferred (May 1, 2026)
- Noridian MAC: Botox LCD L35172 updated (Feb 22, 2026)
- Gold Card expansion: All commercial payers required to honor Gold Card program (Jan 1, 2026)
- Cigna: Zavzpret added Tier 2 Preferred (May 1, 2026)
- Noridian MAC: Botox LCD L35172 updated (Feb 22, 2026)
- Apple Health (Medicaid): Multi-drug formulary update across CGRP classes
- Noridian MAC: Botox LCD L35172 updated (Feb 22, 2026)
- Noridian MAC: Botox LCD L35172 updated (Feb 22, 2026)
- Noridian MAC: Botox LCD L35172 updated (Feb 22, 2026)
- Noridian MAC: Botox LCD L35172 updated (Feb 22, 2026)
- Noridian MAC: Botox LCD L35172 updated (Feb 22, 2026)
- Noridian MAC: Botox LCD L35172 updated (Feb 22, 2026)
Midwest
- WPS MAC: Botox ASC prior authorization demonstration required (Jan 2026)
- WPS MAC: Botox ASC prior authorization demonstration required (Jan 2026)
- WPS MAC: Botox ASC prior authorization demonstration required (Jan 2026)
- WPS MAC: Botox ASC prior authorization demonstration required (Jan 2026)
- IHCP Medicaid: CGRP mAbs step therapy criteria updated (Q1 2026)
- UHC Commercial: Ajovy formulary update
- NGS MAC: Botox LCD updated (Q1 2026)
South
- SB 315 effective Jan 1, 2026: Step therapy protection with 72-hour response mandate
- Cigna: Zavzpret added Tier 2 Preferred (May 1, 2026)
- SB 294 + SB 1227 (Gold Card bills): Pending legislative action
- Medicaid: CMS Interoperability compliance — 72-hr expedited, 7-day standard PA timelines now required
- Cigna: Zavzpret added Tier 2 Preferred (May 1, 2026)
- Cigna: Zavzpret added Tier 2 Preferred (May 1, 2026)
- Medicaid PDL: Qulipta added at Preferred status (Jan 1, 2026)
- Aetna Medicaid: CGRP mAbs step therapy criteria updated (Q1 2026)
- Cigna: Zavzpret added Tier 2 Preferred (May 1, 2026)
- Palmetto/NGS MAC: Botox LCD update
- Cigna: Zavzpret added Tier 2 Preferred (May 1, 2026)
Northeast
- BCBS MA: Botox policy update (Q1 2026)
- Medicaid PDL: Qulipta added at Preferred status (Jan 1, 2026)
- Palmetto MAC: Botox LCD update
- Cigna: Zavzpret added Tier 2 Preferred (May 1, 2026)
- Cigna: Zavzpret added Tier 2 Preferred (May 1, 2026)
Mountain
- Medicaid PDL: Qulipta added at Preferred status (Jan 1, 2026)
- Noridian MAC: Botox LCD L35172 updated (Feb 22, 2026)
- Cigna: Zavzpret Tier 2 coverage update
- Noridian MAC: Botox LCD L35172 updated (Feb 22, 2026)
Regulatory Updates
Gold Card laws, step therapy protections, federal developments, and AI denial restrictions.
Georgia SB 315 — Step Therapy Protection
Georgia enacted SB 315, requiring commercial payers to respond to step therapy exception requests within 72 hours (24 hours for urgent/expedited). Payers must provide a clinical rationale for denials. This applies to all commercial plans regulated in Georgia. Patients denied CGRP therapy due to step therapy may now request expedited exceptions with a faster response timeline.
Colorado Gold Card Expansion
Colorado expanded its Gold Card program to all commercial payers statewide. Providers with a qualifying approval rate over 2 years may apply for PA exemption. This mirrors and extends the Humana national program logic at the state level.
Humana National Gold Card Program
Humana launched a national Gold Card program: providers with ≥92% PA approval rate over the prior 2 years qualify for PA exemption across Humana plans. Standard PA decision turnaround also reduced from 14 to 7 days. Practices with high Humana volume should check eligibility.
Alabama SB 294 + SB 1227 — Gold Card Bills
Two Gold Card bills are pending in the Alabama legislature. SB 294 would establish a provider PA exemption program for commercial plans. SB 1227 is a companion bill covering Medicaid managed care organizations. Passage would align Alabama with Georgia and Colorado. Monitor for committee hearings in Q2 2026.
CMS Medicare Advantage PA Transparency Rule
The CMS finalized rule requires Medicare Advantage plans to publicly report denial rates for specific drug classes beginning Q3 2026. CGRP medications are specifically called out in the reporting guidance. This creates the first federal-level visibility into payer CGRP denial behavior.
Alabama Medicaid — CMS Interoperability Compliance
Alabama Medicaid came into CMS Interoperability and PA rule compliance, mandating 72-hour expedited and 7-day standard PA decision timelines. This applies to all MCOs in the Alabama Medicaid program.
Manufacturer Copay Programs
Current copay and patient assistance program status for all tracked CGRP and migraine medications.
$0/month for eligible commercially insured patients. myAMGEN Assist for uninsured.
Up to $0 copay for eligible commercially insured patients.
$0 copay eligible patients (commercial). LillyCares Foundation for uninsured.
Co-pay support for commercially insured patients; patient assistance for uninsured.
As low as $0/month with Nurtec savings card for eligible patients.
Commercial savings card; patient assistance program for Medicare/uninsured.
Commercial savings card available. Patient assistance for qualifying patients.
Savings program available. Verify eligibility at manufacturer portal. Medicare/Medicaid ineligible for manufacturer programs.
Office-administered — savings typically apply as patient out-of-pocket reduction. Requires billing through practice.
Advocacy Notes
Data points formatted for testimony, comment letters, and payer negotiations.
Universal Step Therapy Despite AHS First-Line Position
Zero of the 1,205 payers tracked in the Vault have removed step therapy requirements for first-line CGRP access, despite the American Headache Society's 2024 position statement. This gap is the most compelling single data point for testimony on step therapy reform.
Zavzpret Access Breakthrough — Scale
Zavzpret was added to the formulary of 80+ payers this quarter. Cigna's Tier 2 Preferred designation (effective May 2026) marks the first time a major national commercial payer has given preferred status to a nasal-spray gepant.
Medicare Botox Documentation Burden Increasing
Medicare's local contractor updates this quarter increased objective clinical scale documentation requirements across 20 MAC jurisdictions covering all geographic regions. This adds administrative burden to headache specialists performing Botox.
CGRP Reauthorization Reduction (OptumRx)
OptumRx eliminated annual CGRP reauthorization nationally, moving to a 2-year interval. This represents a partial industry acknowledgment that CGRP therapy is chronic maintenance, not episodic treatment.
Concurrent CGRP + Gepant Prohibition Trend
Three major payers have now explicitly restricted concurrent CGRP mAb + gepant use. There is no published clinical trial evidence supporting prohibition of this combination — the restrictions are actuarial, not clinical.
Gold Card Expansion (CO, Humana National)
Colorado's commercial Gold Card law and Humana's national program both use a 92% PA approval rate over 2 years as the qualifying threshold. For headache specialists with high CGRP approval rates, this supports the argument that requiring PA creates administrative burden with no clinical benefit.
California Medi-Cal Lookback Reduction
California's Medi-Cal Rx shortened the CGRP step therapy lookback period from 450 to 100 days, effective January 1, 2026. This means California Medicaid patients can now document step therapy failure more quickly, potentially cutting months off the CGRP access pathway.
The Vault's PA Engine uses this policy data to generate letters, check formulary status, and look up payer-specific criteria — free, no account required.
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