Qulipta Health Insurance Denial

• Received a Qulipta Health Insurance Denial? Contact Us
• How Does Qulipta Work? 
• How Long Does It Take Qulipta to Work?
• What Does Qulipta Treat and How Is It Taken?
• How Much Does Qulipta Cost? 
• Is There a Generic Drug for Qulipta?
• Do Insurance Companies Cover Qulipta As a Preventive Treatment for Migraines?
• How do Insurance Companies Evaluate Qulipta Coverage Requests?
• Know These Terms: Medically Necessary, Medically Beneficial, Experimental, and Investigational
• What Duty Do Insurance Companies Have to Members Submitting Claims?
• Contact the Law Offices of Scott Glovsky if You Receive a Qulipta Health Insurance Denial 

Received a Qulipta Health Insurance Denial? Contact Us

Qulipta (atogepant) received FDA approval in September 2021 for the preventive treatment of episodic migraine in adults. AbbVie submitted a supplemental New Drug Application to the FDA to expand the indication for Qulipta to include the prevention of chronic migraine. This article addresses Qulipta health insurance coverage claims, detailing how insurance companies make decisions regarding medical necessity. It also covers the steps necessary if you have received a Qulipta health insurance denial, and how an experienced health insurance claim denial attorney from the Law Offices of Scott Glovsky can help.

How Does Qulipta Work? 

Qulipta is an oral medication used in the prevention of migraine headaches. Qulipta blocks calcitonin gene-related peptide (CGRP) from binding to its receptors. CGRP is a protein that causes vasodilation, pain, and inflammation associated with migraines. By blocking the CGRP, which is released in the brain and surrounding nerves, Qulipta helps reduce the frequency of migraine attacks.

How Long Does It Take Qulipta to Work?

Clinical trials have shown that Qulipta can significantly reduce the number of migraine days per month, and the need for acute migraine treatments. Some individuals will experience a reduction in migraine days within the first day or week, but it can take up to 12 weeks for the full effect of Qulipta to be felt. You can read more about Qulipta here.

What Does Qulipta Treat and How Is It Taken?

Qulipta treats and helps prevent migraine headaches in adults, both episodic and chronic. Qulipta is an oral tablet that is taken once daily. The dosage depends on whether you are treating episodic or chronic migraines, as well as other medications you are taking, and whether you suffer from low kidney function. Qulipta is a preventative medication and is not intended to treat active migraine attacks.

How Much Does Qulipta Cost? 

The list price of Qulipta in 2025 is $1,147.21 for 30 tablets, regardless of whether the strength is 10 mg, 30 mg, or 60 mg. Prices vary according to the pharmacy used, the type of insurance, and whether manufacturer’s coupons or savings programs are available. With the Qulipta Complete Savings Program, you may be able to obtain free or discounted Qulipta if you meet the eligibility requirements.

Is There a Generic Drug for Qulipta?

There is currently no generic version of Qulipta. Drug companies like AbbVie, the maker of Qulipta, have patents that protect their drugs from generic competition. The earliest a generic version of Qulipta could enter the market is January 30, 2035. If you notice an online pharmacy selling a generic version of Qulipta, the drug is likely counterfeit and could also be unsafe.

Do Insurance Companies Cover Qulipta As a Preventive Treatment for Migraines?

The type of health insurance you have will determine whether Qulipta will be covered. If you have a government health insurance program like Medicaid, Qulipta will probably be covered, but there may be exceptions. Medicaid helps low-income individuals and families with the cost of health insurance.

If you are over 65, you likely have Medicare, another government program. Since regular Medicare does not provide drug coverage, you will have your prescription drug coverage either under a Medicare Advantage Plan (Part C) or a Medicare Supplemental Plan (Part D). If you have a commercial private insurance company like Blue Shield, Healthnet, Anthem, Aetna, a Medi-Cal Managed Care Plan, UnitedHealthcare, or Kaiser Permanente, your coverage standards could vary significantly.

If the drug is deemed medically unnecessary, your insurer could refuse to pay for Qulipta. Whether you have an ERISA plan or a non-ERISA plan will determine how you will respond to claim denials. Most private employers offer employees ERISA (Employee Retirement Income Security Act of 1974) plans, except for government employee plans, religious organization plans, Covered California individual and family plans, business plans that only cover business owners, and individual and family plans purchased through a private insurance company.

How do Insurance Companies Evaluate Qulipta Coverage Requests?

When a new drug is approved by the FDA, health insurance companies evaluate coverage based on internal pharmacy or medical policies. The insurer’s pharmacists, doctors, and other medical practitioners will develop internal clinical policies after researching the drugs to determine which drugs are medically necessary for which situations. Once these policies are developed, they are brought before a group of external doctors for a vote. The votes of these doctors can be influenced by financial gains or job promises from insurance companies, leading to overly restrictive policies.

Know These Terms: Medically Necessary, Medically Beneficial, Experimental, and Investigational

Insurers may deem a drug medically necessary if it is required to treat the signs or symptoms of a specific disease or condition. Insurers often require prior authorization before claiming that the drug is medically necessary and is not experimental or investigational. A drug can be medically beneficial for a patient, yet still deemed not medically necessary, since in most cases, different drugs and procedures can treat the same condition. Of course, insurance companies often favor less expensive treatment options.

A variety of drugs and procedures can oftentimes treat the same conditions. Step therapy is a form of prior authorization that requires patients to try an alternative (less expensive) drug for 60 days before re-evaluating the initial drug request. An insurer may deem a drug not medically necessary because an alternative exists. Certain exemptions may be present for step therapy in California, but the process can be complex. Step therapy can sometimes harm patients by preventing them from getting approval for the name-brand drug prescribed by their doctors.

An insurance company may also decide that a drug is experimental or investigational, often because it is being prescribed off-label (for a use not approved by the FDA). The policy definitions of "experimental" and "investigational" will determine whether the drug will be covered. If evidence fails to draw conclusions regarding the health outcomes of a specific drug, it may be called experimental. If scientific evidence suggests that alternative drugs could be just as effective, it could be deemed investigational.

What Duty Do Insurance Companies Have to Members Submitting Claims?

Insurers will review the submitted claims and then determine whether to approve or deny them. The insurance companies have several duties, including:

• Thoroughly investigate claim requests
• Fully inquire into all potential reasons that would support requests for care
• Promptly respond to claim requests
• Appoint and employ qualified medical professionals to make claim review decisions.

Contact the Law Offices of Scott Glovsky if You Receive a Qulipta Health Insurance Denial 

The Law Offices of Scott Glovsky has represented injured consumers and victims of wrongful business practices for over two decades. Our firm focuses on health insurance bad faith, other types of insurance bad faith, catastrophic personal injury, sexual abuse, and consumer-related litigation. If your claim has been denied, we will fight for justice on your behalf. Attorney Scott Glovsky believes in holding wrongdoers accountable, regardless of the company's size and power.