CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Aimovig (erenumab) prior authorization request form and coverage criteria

This document is the insurer's prior authorization form and requirements for Aimovig (erenumab) coverage for migraine prevention, used by prescribers requesting initial or reauthorization for Blue Cross Blue Shield - South Carolina members.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyAimovig (erenumab) prior authorization request form and coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the Aimovig Prior Authorization Request Form with required clinical documentation (initial or reauthorization) to OptumRx via fax or CoverMyMeds.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial + Reauthorizationform pages / request types

4–14 or ≥15eligibility headache-frequency thresholds

≥2 monthsrequired trial duration

844-403-1029submission fax

855-811-2218authorization contact

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Coverage Criteria for Aimovig (erenumab)

Initial Therapy

Covered when ALL of the following are met:

Diagnosis and frequency: Patient meets either episodic migraine criteria (4–14 migraine days per month and no more than 14 headache days per month) OR chronic migraine criteria (≥15 headache days per month with ≥8 migraine days per month for at least 3 months).episodic: 4–14 migraine days/month; chronic: ≥15 headache days/month with ≥8 migraine days for ≥3 months

Either the episodic OR chronic pathway must be met

Medication overuse headache (MOH) has been considered and any potentially offending medications have been discontinued as appropriate.

MOH must be assessed prior to approval

Prior preventive therapy trials or contraindication: Documented history of failure or intolerance after at least a two-month trial of specified agents where indicated (Elavil/amitriptyline or Effexor/venlafaxine; Depakote/divalproex sodium or Topamax/topiramate; ONE of the listed beta blockers: atenolol, propranolol, nadolol, timolol, or metoprolol), OR documentation of contraindication to the listed agents as specified on the form.>=2 months for required trials

Form asks about failures/intolerances and contraindications to specific agents/classes

Reauthorization

Covered when ALL of the following are documented:

Demonstrated clinical benefit: Patient has experienced a positive response to therapy demonstrated by a reduction in headache frequency and/or intensity.

Required for continued coverage

Decreased acute medication use: Use of acute migraine medications (e.g., NSAIDs, triptans) has decreased since initiation of CGRP therapy.

Used to document clinical improvement

MOH monitoring for chronic migraine patients: For patients with chronic migraine, documentation that the patient continues to be monitored for medication overuse headache (MOH).

Applies to chronic migraine patients on reauthorization

The prior authorization form does not list any blanket exclusions; instead, coverage decisions are based on whether the specific documentation requested on the form is provided. Approvals for initial therapy require completion of the form items that establish diagnosis (episodic or chronic migraine), headache/migraine frequency thresholds, assessment of medication overuse headache, and documentation of prior preventive therapy trials or contraindications as applicable.

Requests may be denied if the form is incomplete or if the clinical information does not meet the stated criteria. The form explicitly notes that "this request may be denied unless all required information is received," and reauthorization requires documentation of clinical benefit (reduced headache frequency/intensity) and, for chronic migraine, continued monitoring for medication overuse headache. Failure to document the required trial history, contraindications, or response to therapy will result in non-approval.

Clinical Definitions & Thresholds

Episodic migraine — migraine days per month (4-14)

Episodic migraine threshold4 to 14 migraine days per month (and no more than 14 headache days per month)

ApplicationApplies to initial authorization pathway when clinician selects episodic migraine on the form

Documentation requiredForm asks provider to confirm 'four to 14 migraine days per month, but no more than 14 headache days per month'

Chronic migraine — headache days per month (>= 15) with >=8 migraine days for >=3 months

Chronic migraine threshold>= 15 headache days per month, of which >= 8 are migraine days, for at least 3 months

ApplicationApplies to initial authorization pathway when clinician selects chronic migraine on the form

What Providers Must Do

Prior Authorization

Form completion required

Prior authorization is required for Aimovig. Complete and submit the Aimovig Prior Authorization Request Form (both initial and reauthorization sections as applicable). The form includes required provider and medication information and must be signed and dated by the prescriber.

Aimovig Prior Authorization Request Form (Page 1 and Page 2) — fax to 844-403-1029 or submit via CoverMyMeds/OptumRx where available
Provider information required: member name, provider name, insurance ID#, NPI#, specialty, DOB, office phone/fax, address
Medication information required: medication name, strength, dosage form, directions for use
Prescriber's signature and date required

Denial Risk

Incomplete submission

This request may be denied unless all required information on the Aimovig Prior Authorization Request Form is completed and submitted. Ensure all questions on the initial or reauthorization sections are answered and supporting documentation (treatment history, trial durations, and any contraindications) is included.

Clinical Background

Aimovig (erenumab) is a CGRP-pathway targeted monoclonal antibody indicated for migraine prevention. The prior authorization form is organized to separate the episodic migraine pathway (documenting 4–14 migraine days per month and no more than 14 headache days) from the chronic migraine pathway (documenting ≥15 headache days per month, with ≥8 migraine days for ≥3 months), and it also asks about medication overuse headache and prior preventive therapy trials. Reauthorization questions focus on demonstrated clinical benefit (reduction in frequency and/or intensity) and decreased use of acute migraine medications.

Key Definitions

Definition — Episodic migraine: 4 to 14 migraine days per month, and no more than 14 headache days per month

DefinitionEpisodic migraine: patient has 4 to 14 migraine days per month

Headache days limitNo more than 14 headache days per month

Use in formQuestion 2 on the Initial Authorization form asks providers to confirm this criterion

Definition — Chronic migraine: >=15 headache days per month, of which >=8 are migraine days, for >=3 months

DefinitionChronic migraine: >=15 headache days per month

Migraine-day requirementOf those headache days, at least 8 must be migraine days for at least 3 months

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyAimovig (erenumab) prior authorization request form and coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the Aimovig Prior Authorization Request Form with required clinical documentation (initial or reauthorization) to OptumRx via fax or CoverMyMeds.

SourceLink

On This Page

Form confirmationQuestion on form: 'Does the patient have greater than or equal to 15 headache days per month, of which at least eight must be migraine days for at least three months?'

Required trial duration for preventive agents (>= 2 months)

Minimum trial duration>= 2 months for each listed preventive agent when documenting failure or intolerance

Agents referencedExamples on form include amitriptyline, venlafaxine, divalproex sodium, topiramate, and specified beta blockers

Alternative to trialForm allows documentation of contraindication to the listed agents instead of trial where applicable

Incomplete or unsigned forms may lead to denial or processing delays
Contact OptumRx prior authorization line for assistance: 855-811-2218 (Mon–Fri 8 a.m.–1 a.m. ET; Sat 9 a.m.–6 p.m. ET)

Step Therapy

Required trials of prior preventive therapies

Document failure or intolerance to required prior preventive therapies. For initial authorization, the form requires documentation that the patient has had trials of specified agents for at least two months or has contraindications to those agents.

At least a two-month trial (or documented intolerance/contraindication) of Elavil (amitriptyline) or Effexor (venlafaxine), or documentation of contraindication to BOTH
At least a two-month trial (or documented intolerance/contraindication) of Depakote/Depakote ER (divalproex sodium) or Topamax (topiramate), or documentation of contraindication to BOTH
At least a two-month trial (or documented intolerance/contraindication) of ONE beta blocker (atenolol, propranolol, nadolol, timolol, or metoprolol), or documentation of contraindication to ALL listed beta blockers
For chronic migraine, documentation of ≥15 headache days/month with ≥8 migraine days/month for ≥3 months and consideration/discontinuation of medication overuse headache triggers as applicable

Question 4 on the Initial Authorization form captures this requirement

Medication overuse headache (MOH) — form asks consideration and discontinuation of offending meds prior to approval

MOH considerationForm asks whether medication overuse headache has been considered

Offending medicationsForm requests that potentially offending medication(s) have been discontinued prior to approval

Applies toRequired as part of initial authorization assessment