CurrentAvMedPolicy N/A

Migraine Treatment: Injectable CGRP Antagonists (Prior Authorization / Step-Edit)

Prior authorization and step-edit requirements for prescribing injectable calcitonin gene-related peptide (CGRP) antagonists (Aimovig, Emgality, Ajovy) for migraine and episodic cluster headache prophylaxis for AvMed members.

Policy Summary

PayerAvMed

PolicyMigraine Treatment: Injectable CGRP Antagonists (PA/Step-Edit)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with complete documentation including prescriber signature, diagnosis, dosing, weight (if applicable), and evidence of required prior medication trials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3agents listed (preferred + non-preferred)

≥4minimum migraine days for eligibility

2prophylactic classes failed required

18+ / 6+ & ≥45 kgage/weight requirements

Coverage Criteria

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Age and diagnosis: Member meets age/weight requirements: Aimovig & Emgality: >=18 years; Ajovy: >=6 years and >=45 kg.

Migraine frequency: Member has chronic or episodic migraine with >=4 migraine headache days per month.>=4 days/month

Prior medication trials: Member has failed a 2-month trial of at least one medication from TWO different migraine prophylactic classes (examples: anticonvulsants, beta blockers, antidepressants, candesartan requires prior authorization).2 classes, 2 months each as applicable

Injectable or oral CGRP inhibitors also require prior authorization.

Ajovy-specific step requirement: For Ajovy requests in members >=18 years: member must have tried and failed BOTH preferred agents Aimovig and Emgality and meet all prior authorization criteria.

Ajovy is non-preferred; failure of both preferred agents required.

No concurrent CGRP inhibitors: Requested medication will NOT be used in combination with another injectable CGRP inhibitor (e.g., Aimovig, Ajovy, Emgality, Vyepti) or an oral CGRP inhibitor indicated for migraine prevention (e.g., Nurtec ODT, Qulipta).

Concurrent CGRP inhibitor with Botox (onabotulinumtoxinA)

Covered when ALL of the following are met for concurrent use with Botox

Diagnosis and persistent frequency: Member has a diagnosis of chronic or episodic migraine and continues to experience >=4 migraine headache days per month after prior therapies.>=4 days/month

Verified by chart notes and/or pharmacy paid claims.

Prior trials before combination: Member has failed a 2-month trial of at least one medication from TWO different migraine prophylactic classes (examples: anticonvulsants, beta blockers, antidepressants, candesartan requires prior authorization).2 months per trial

Member must also have either an inadequate response to a 2-month trial of an injectable/oral CGRP inhibitor OR an inadequate response to a 6-month trial (2 injection cycles) of Botox.

Episodic cluster headache (Emgality only)

Covered when ALL of the following are met for episodic cluster headache (Emgality only)

Frequency: Member has between one headache every other day and eight headaches per day.

Prior trials: Member has failed at least a 1-month trial of at least ONE standard generic prophylactic therapy for cluster headache (examples: suboccipital steroid injection, verapamil, lithium, warfarin, topiramate).1 month

Therapies supported by guideline evidence; prior therapies will be verified via pharmacy claims or chart notes.

No combination therapy: Requested Emgality will NOT be used in combination with another injectable CGRP inhibitor (e.g., Aimovig, Ajovy, Emgality, Vyepti) or an oral CGRP inhibitor indicated for migraine prevention (e.g., Nurtec ODT, Qulipta).

Use of free drug samples or sample medication to start therapy does not satisfy the policy’s step‑therapy or prior authorization requirements and therefore does not meet the criteria for approval. Documentation must show medically necessary trials and failures of the required prophylactic therapies or preferred CGRP agents as specified in the prior authorization criteria; sampling alone cannot be used to fulfill those requirements.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for listed injectable CGRP agents. Aimovig and Emgality are preferred agents and require PA. Ajovy is non-preferred and requires prior failure of both preferred agents (Aimovig and Emgality) in addition to meeting all PA criteria.

Aimovig (erenumab) — preferred
Emgality (galcanezumab) — preferred
Ajovy (fremanezumab) — non-preferred; requires failure of BOTH preferred agents and meeting all PA criteria

Step Therapy

Step Edits and Preferred Agent Failure

Member must have tried and failed a trial of medications from two different migraine prophylactic classes (for at least 2 months each) prior to approval. For Ajovy requests in adults (≥18 years), member must have tried and failed BOTH preferred agents (Aimovig and Emgality) and meet all other PA criteria.

Required failure of medications from TWO different prophylactic classes (examples: anticonvulsants, beta blockers, antidepressants, candesartan)
Trials should follow guideline-supported agents (AHS/AAN/ICSI evidence) and be of adequate duration (typically 2 months)
Ajovy (non-preferred) requires documented trials and failures of Aimovig and Emgality

Documentation Required

Required Form Fields and Supporting Documentation

Prescriber signature is required on the PA request (hand-signed; preprinted stamps are not valid). Include complete member and prescriber information, diagnosis with ICD code (if applicable), dosing schedule, length of therapy, and any supporting clinical documentation.

Prescriber signature (hand-signed) — required
Member name, AvMed ID, DOB
Prescriber name, NPI, office contact, phone and fax numbers
Diagnosis and ICD code, dosing schedule, length of therapy, weight and date obtained (if applicable)

Denial Risk

Form Completeness — Risk of Delay or Denial

Incomplete, incorrect, or illegible information on the PA request form (including missing prescriber signature or contact information) can delay processing or result in denial.

Preprinted signature stamps are not valid
Ensure phone and fax numbers are accurate to avoid follow-up delays
All required form fields should be completed legibly

Documentation Required

Missing Clinical Documentation — Provide Supporting Evidence

All clinical criteria boxes checked on the form must be supported by documentation (lab results, diagnostics, chart notes). Failure to provide documentation supporting each checked clinical criterion may lead to denial.

Provide chart notes documenting migraine frequency (≥4 migraine days/month) and prior prophylactic medication trials and outcomes
Attach documentation of prior trials and reasons for discontinuation or failure
If requesting a switch from another injectable CGRP antagonist, document whether the member will discontinue the prior agent

Definitions

Chronic/Episodic Migraine (policy definition)

Definition (policy)Chronic or Episodic Migraine Headache defined as having >= 4 migraine headache days per month

Implication for coverageMember must meet this frequency criterion in order to satisfy initial therapy requirements for migraine prophylaxis

VerificationFrequency and related documentation may be verified via chart notes or pharmacy claims

Background

Calcitonin gene‑related peptide (CGRP) monoclonal antibodies — Aimovig (erenumab), Emgality (galcanezumab), and Ajovy (fremanezumab) — are indicated in this policy for migraine prophylaxis when the member meets age/weight and trial requirements. Emgality additionally has a covered indication for episodic cluster headache, where the recommended cluster dosing is a 300 mg SC dose at onset and then monthly for the cluster period. For migraine prophylaxis, dosing examples include Aimovig 70 mg monthly (or 140 mg monthly for some members) and Emgality initial 240 mg loading dose then 120 mg monthly; members must meet the policy definition of chronic or episodic migraine (≥4 migraine headache days per month) and required prior therapy trials to qualify for coverage.

Initial Therapy Criteria & Dosing

Dosing and quantity limits

Recommended dosing and quantity limits as listed

Aimovig dosing: Initial: 70 mg SC once monthly; some members may benefit from 140 mg once monthly (given as two consecutive 70 mg injections). Quantity limits: 70 mg/mL (1 mL/30 days); 140 mg dose (2 mL/30 days).

If using 140 mg dose, must use package labeled specifically for 140 mg/mL.

Ajovy dosing: Adults: 225 mg SC monthly or 675 mg every 3 months. Pediatrics (>=6 and <=17 years) and >=45 kg: 225 mg SC monthly. Quantity limits: 225 mg/1.5 mL; 1 syringe per 30 days or 3 syringes per 90 days.

Ajovy is non-preferred and requires prior failure of both preferred agents for adults.

Emgality dosing: Initial: 240 mg SC as a single loading dose followed by 120 mg once monthly for migraine prophylaxis. For episodic cluster headache: 300 mg SC at onset then once monthly for duration of cluster period. Quantity limits: 120 mg/mL; 1 mL per 30 days with one-time loading dose of 2 mL; cluster dosing uses 100 mg/mL prefilled syringe for 300 mg.

Continuation and Switching Criteria

Therapy substitution / discontinuation

When switching therapy

Discontinuation documentation: If member will discontinue a previously prescribed injectable CGRP antagonist, prescriber must list the medication to be discontinued and the medication to be initiated with effective dates on the request form.

Form includes fields for medications and effective dates; provide weight if applicable.

Step Therapy Requirements

Step	Requirement
Step 1	Member must have failed a 2-month trial of at least one medication from TWO different migraine prophylactic classes (examples: anticonvulsants, beta blockers, antidepressants, candesartan [requires prior authorization], injectable/oral CGRP inhibitors).
Step 2	For Ajovy (fremanezumab) requests in members ≥18 years: member must have tried and failed BOTH preferred agents (Aimovig and Emgality) and meet all prior authorization criteria for Ajovy.
Additional	Requested medication will NOT be used in combination with another injectable CGRP inhibitor or an oral CGRP inhibitor indicated for migraine prevention.

Quantity Limits by Agent

Aimovig (erenumab) — strengths & quantity

Available strengths70 mg/mL (1 mL) and 140 mg dose (2 mL; given as two consecutive 70 mg injections)

Usual dose for migraine prophylaxisInitial: 70 mg SC once monthly; some members may benefit from 140 mg once monthly

Quantity limit70 mg/mL (1 mL) per 30 days; 140 mg dose (2 mL) per 30 days; 140 mg must use package labeled specifically for 140 mg/mL

Ajovy (fremanezumab) — strengths & quantity

Available strength225 mg per 1.5 mL prefilled syringe

Usual dosing regimensAdults: 225 mg SC monthly or 675 mg every 3 months; Pediatrics >=6 years and <=17 years and >=45 kg: 225 mg SC monthly

Quantity limit225 mg/1.5 mL; 1 syringe per 30 days or 4.5 mL (3 syringes) per 90 days

Emgality (galcanezumab) — strengths, quantity & cluster dosing note

Primary strength/maintenance120 mg/mL; 1 mL (1 auto-injector or prefilled syringe) once monthly after loading dose

Loading and migraine dosingInitial loading dose: 240 mg SC as a single dose followed by 120 mg once monthly

Episodic cluster dosing & noteFor episodic cluster headache: 300 mg SC at onset then once monthly; 300 mg uses 100 mg/mL prefilled syringe