CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Aimovig Prior Authorization Request Form

Prior authorization form used by Blue Cross Blue Shield - South Carolina / OptumRx to request coverage for Aimovig for episodic or chronic migraine, documenting diagnostic criteria, prior medication trials/intolerances/contraindications, and reauthorization response metrics.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyAimovig Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeForm / prior authorization

Effective Date

Next Review Date

Key ActionComplete and submit the Aimovig prior authorization form (including member, provider, medication, initial or reauthorization sections and prescriber signature) to OptumRx/CoverMyMeds; incomplete information may lead to denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Indications referenced (episodic vs chronic)

>=2 monthsMinimum trial duration (prior preventives)

8Minimum migraine days (chronic definition)

15Headache days threshold (chronic)

Coverage Summary

This is a prior authorization form for Aimovig (erenumab) for prevention of episodic or chronic migraine. Coverage is considered when the form documents the applicable diagnostic category (episodic versus chronic migraine) and the specified frequency thresholds for each, documents prior preventive medication trials, intolerances, or contraindications, and for reauthorization documents treatment response metrics such as reduction in headache frequency/intensity and decreased use of acute migraine medications.

Threshold summary

Episodic migraine frequency4–14 migraine days per month; no more than 14 headache days per month

Chronic migraine frequency>= 15 headache days per month with >= 8 migraine days for at least 3 months

Required duration of prior preventive medication trialAt least a two-month trial for listed preventive agents

Provider Actions

Prior Authorization

Submit prior authorization form

Complete and submit the Aimovig prior authorization form to OptumRx/CoverMyMeds. The form may be faxed to 844-403-1029 or submitted via CoverMyMeds; OptumRx has partnered with CoverMyMeds to accept requests. Provide all required sections — member information, provider information, medication information, indicate whether this is an initial request or reauthorization, and include the prescriber's signature. Incomplete information may lead to denial.

Fax to 844-403-1029 or submit via CoverMyMeds (go.covermymeds.com/OptumRx).
Required sections: member information, provider information, medication information.
Indicate request type: initial authorization or reauthorization.
Include prescriber's signature and date.

Documentation Required

Document migraine diagnosis and frequency

Document whether the patient has episodic or chronic migraine and record the monthly migraine/headache day counts according to the form thresholds. Use the form checkboxes to indicate diagnosis and confirm the numeric frequency criteria for episodic versus chronic migraine.

Episodic: 4–14 migraine days per month and no more than 14 headache days per month; Chronic: ≥15 headache days per month with ≥8 migraine days for at least 3 months.

Documentation Required

Record prior preventive medication trials or contraindications

Document prior preventive medication trials of at least a two-month duration or intolerance to listed agents, or document contraindications as applicable. Use the form checkboxes to indicate failures/intolerances after at least a two-month trial or that contraindications exist.

Amitriptyline (Elavil) and venlafaxine (Effexor)
Divalproex sodium (Depakote/Depakote ER) and topiramate (Topamax)
One of the following beta blockers: atenolol, propranolol, nadolol, timolol, metoprolol (or documentation of contraindication to all listed beta blockers)

Documentation Required

Reauthorization outcome measures

For reauthorization, document clinical response to therapy. The form requires evidence of reduced headache frequency and/or intensity, decreased use of acute migraine medications since starting CGRP therapy, and continued monitoring for medication overuse headache (MOH) in patients with chronic migraine.

Reduction in headache frequency and/or intensity since starting therapy.
Decreased use of acute migraine medications (e.g., NSAIDs, triptans).
For chronic migraine patients: ongoing monitoring for medication overuse headache (MOH).

Denial Risk

Risk of denial for incomplete form

Requests may be denied unless all required information on the form is received. Ensure the form is complete and signed; missing or incomplete information can result in denial and may necessitate contact with prior authorization support.

Incomplete or missing required information may lead to denial.
For questions about the prior authorization process, contact OptumRx at 855-811-2218.

Background

This payer prior authorization request form is for Aimovig, a CGRP-pathway monoclonal antibody used for migraine prevention. The form captures whether the patient has episodic or chronic migraine and requests documentation of monthly migraine/headache day counts per the form's thresholds, prior preventive medication trials (or documented intolerances) and contraindications for listed agents (including amitriptyline, venlafaxine, divalproex/divalproex ER, topiramate, and selected beta blockers), and for reauthorization the form captures response measures such as reduction in headache frequency/intensity and decreased use of acute migraine medications. The form also asks that medication overuse headache (MOH) be considered and any potentially offending medications discontinued and that chronic migraine patients continue to be monitored for MOH.

OpenPayer

Aimovig Prior Authorization Request Form

Coverage Summary

Medical Necessity Criteria

Not Covered / Experimental

Coding

Provider Actions

Background

Revision History