CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Ajovy (fremanezumab) prior authorization for migraine prevention

Prior authorization form and criteria for coverage of Ajovy for prevention of episodic and chronic migraine; intended for prescribers submitting PA requests.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyAjovy (fremanezumab) prior authorization for migraine prevention

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Ajovy PA form documenting diagnosis, migraine/headache frequency, prior preventive trials or contraindications, MOH consideration, and follow-up response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4-14episodic migraine criterion

>=15/>=8chronic migraine criterion

2 mominimum trial duration

Aimovig + Emgalityrequired prior CGRP trials

Coverage Criteria for Ajovy (fremanezumab)

Initial Authorization Criteria

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyAjovy (fremanezumab) prior authorization for migraine prevention

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the Ajovy PA form documenting diagnosis, migraine/headache frequency, prior preventive trials or contraindications, MOH consideration, and follow-up response.

SourceLink

On This Page

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Diagnosis requirement

Episodic migraine node: 4 to 14 migraine days per month and no more than 14 headache days per month4-14 migraine days/month
Chronic migraine node: >=15 headache days per month, with >=8 migraine days per month for at least 3 months>=15 / >=8 for >=3 months

Medication overuse and discontinuation: Medication overuse headache has been considered and potentially offending medications have been discontinued (where applicable)

Form asks consideration and discontinuation

Prior preventive therapies: History of failure after at least a 2-month trial or intolerance, or documented contraindication to specified preventive medications as indicated on the form2-month trials; or documented contraindications

Specific agents listed include amitriptyline (Elavil), venlafaxine (Effexor), divalproex sodium (Depakote), topiramate (Topamax), and one of the listed beta blockers (atenolol, propranolol, nadolol, timolol, metoprolol)

Prior CGRP therapy requirement: Trial and failure, contraindication, or intolerance to BOTH Aimovig and Emgality is requiredtrial and failure or contraindication to both Aimovig and Emgality

Documented on the form

Continuation Criteria

Continuation/Follow-up:

Response to therapy: Patient experienced a positive response to therapy demonstrated by a reduction in headache frequency and/or intensitydocumented improvement

Form asks yes/no

Reduced acute medication use: Use of acute migraine medications has decreased since the start of CGRP therapydocumented reduction

Form asks yes/no

MOH monitoring for chronic migraine: For chronic migraine, continued monitoring for medication overuse headache is documentedongoing monitoring

Form asks yes/no

Key Coding and Clinical Thresholds

PA submission portal / faxneutral

No codes listed

inv-06: Episodic migraine frequency

Episodic migraine frequency4–14 migraine days per month

Headache days limitNo more than 14 headache days per month

Form question referenceDocumented on initial authorization form (question 2)

inv-07: Chronic migraine frequency

Chronic migraine frequency (headache days)>=15 headache days per month

Chronic migraine frequency (migraine days)Of those, at least 8 must be migraine days per month

Duration requirementPattern present for at least 3 months

inv-08: Minimum trial duration for listed preventive medications

Minimum trial durationAt least a 2-month trial for listed preventive medications

Applies to multiple agentsSpecified agents include amitriptyline, venlafaxine, divalproex, topiramate, beta blockers

Documented failure or intoleranceHistory of failure after the 2-month trial or intolerance must be documented on the form

Requirements and Actions for Providers

Prior Authorization

Prior Authorization Required

Prior authorization is required for AJOVY (fremanezumab). Complete the Ajovy Prior Authorization Request Form documenting the diagnosis (episodic or chronic migraine), migraine/headache day counts, medication trials and outcomes, and prescriber signature/date. Submit the completed form to the payer; requests may be denied if the form is incomplete.

AJOVY prior authorization form must be used (Ajovy Prior Authorization Request Form).
Include documentation of diagnosis: episodic migraine (4–14 migraine days/month, ≤14 headache days/month) or chronic migraine (≥15 headache days/month with ≥8 migraine days/month for ≥3 months).
Attach prescriber signature and date.

Documentation Required

Required Form Fields

Complete all required provider and medication fields on the Ajovy PA form so the request can be processed without delay.

Provider information (required): Member name; Provider name; Insurance ID#; Provider NPI; Specialty; Provider office phone and fax; Office street address, city, state, ZIP; Date of birth.
Medication information (required): Medication name, strength, dosage form, directions for use.
Prescriber attestation: Prescriber signature, date, and any additional comments/clinical details relevant to the review.

Step Therapy

Required Prior Preventive Trials

Provide documentation of prior trials and either failure, intolerance, or contraindication to the specified oral preventive therapies before AJOVY initiation, unless clinically contraindicated.

Trials required (document trial duration and outcome): amitriptyline (Elavil) or venlafaxine (Effexor) — trial ≥2 months with failure or intolerance, or documented contraindication to both.
divalproex sodium (Depakote/Depakote ER) or topiramate (Topamax) — trial ≥2 months with failure or intolerance, or documented contraindication to both.
Trial and failure, intolerance, or contraindication to at least one of the following beta blockers: atenolol, propranolol, nadolol, timolol, or metoprolol (documented duration/outcome).
Document prior trial and failure, intolerance, or contraindication to both CGRP monoclonal antibodies Aimovig (erenumab) and Emgality (galcanezumab), when applicable.

Denial Risk

Denial Risk for Incomplete Submission

This request may be denied unless all required information on the Ajovy prior authorization form and supporting documentation (diagnosis, headache day counts, prior preventive trial details, prescriber signature) are provided.

Incomplete submissions lacking required provider/medication fields, diagnosis/headache frequency, or documentation of prior trials may be denied.
If additional information is requested, respond promptly to avoid denial or delay.

Background on Ajovy and Clinical Context

Ajovy (fremanezumab) is a calcitonin gene-related peptide (CGRP) pathway monoclonal antibody indicated in this policy for prevention of migraine. The PA form distinguishes episodic migraine — defined as 4 to 14 migraine days per month (no more than 14 headache days per month) — from chronic migraine — defined as ≥15 headache days per month with ≥8 migraine days per month for at least 3 months. The form also asks about consideration of medication overuse headache (MOH) and documents prior preventive therapy trials and response for continuation.

Clinical Definitions and Considerations

inv-14: Episodic migraine

DefinitionPatient has 4 to 14 migraine days per month

Headache days capNo more than 14 headache days per month

Source on formAsked on initial authorization form (question 2)

inv-15: Chronic migraine

Headache days threshold>=15 headache days per month

Migraine days requirementAt least 8 of the headache days must be migraine days per month

Required durationCriteria require this pattern for at least 3 months

inv-16: Medication overuse headache (MOH)

MOH considerationForm asks whether medication overuse headache (MOH) has been considered

Discontinuation of offending medsForm asks whether potentially offending medications have been discontinued where applicable

Ongoing monitoringFor chronic migraine, form asks whether monitoring for MOH continues during follow-up