CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Emgality (galcanezumab) prior authorization

Prior authorization form and requirements for Emgality (galcanezumab) requests for Blue Cross Blue Shield - South Carolina members; applies to providers submitting initial and reauthorization requests for migraine and cluster headache treatment.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyEmgality (galcanezumab) prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form documenting diagnosis, headache frequency thresholds, prior medication trials or contraindications, and for reauthorization show clinical response and reduced acute medication use.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial + Reauthform sections included

Migraine thresholdsnumeric criteria

Medication trialsprior trials required

Faxfax option

Coverage Criteria for Emgality (galcanezumab)

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Initial Authorization

Covered when ALL of the following are met as documented on the form

Diagnosis

Episodic migraine criteria: 4–14 migraine days per month and no more than 14 headache days per month4-14 migraine days/month; ≤ 14 headache days/month
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Chronic migraine criteria: ≥15 headache days per month, of which at least 8 must be migraine days for at least 3 months≥15 headache days/month; ≥ 8 migraine days/month for ≥ 3 months
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Episodic cluster headache criteria: At least two cluster periods lasting 7–365 days separated by pain-free periods of at least 3 months2 cluster periods, 7-365 days, separated by ≥ 3 months
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Medication overuse consideration: Medication overuse headache has been considered and potentially offending medications have been discontinued
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Documentation: Required documentation is provided on the form (diagnosis selection, headache/migraine day counts, relevant clinical history)

Complete member and provider information and prescriber signature per form

Prior Medication Trials

Initial Authorization — Medication trial requirements (documented failures or contraindications required)

Prior medication trials or contraindications: Documentation of history of failure (after at least a 2-month trial) or intolerance to specified agents, or documentation of contraindications to the listed agents≥2 month trial for failed agents where specified

Agents listed on form: failure or intolerance to amitriptyline (Elavil) or venlafaxine (Effexor), OR documented contraindication to BOTH; failure or intolerance to divalproex (Depakote/Depakote ER) or topiramate (Topamax), OR contraindication to BOTH; failure or intolerance to ONE of the following beta blockers: atenolol, propranolol, nadolol, timolol, or metoprolol, OR contraindication to ALL listed beta blockers

Reauthorization

Covered when ALL of the following are met

Clinical response: Patient has experienced a positive response to therapy, demonstrated by reduction in headache frequency and/or intensity

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

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MOH monitoring for chronic migraine: For chronic migraine, patient continues to be monitored for medication overuse headache (MOH)

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The form does not list standalone exclusions, but approval is contingent on meeting the documented criteria. In practice, absence of required prior medication trials or documented contraindications to the listed agents will effectively exclude approval. Specifically, the initial authorization requires meeting one of the diagnosis frequency thresholds (episodic migraine, chronic migraine, or episodic cluster headache) and documentation of failure (after at least a 2‑month trial) or intolerance to the specified agents — including amitriptyline/venlafaxine, divalproex/topiramate, and a beta blocker (atenolol, propranolol, nadolol, timolol, or metoprolol) — or documented contraindications to those agents. If those trial/contraindication requirements are not met, the request will effectively be excluded from coverage.

Providers must supply all requested information on the prior authorization form. The form states: This request may be denied unless all required information is received. Missing documentation that supports diagnosis, prior medication trials/contraindications, reauthorization response measures, or the prescriber signature may result in denial of the request.

Provider Requirements and Submission Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required for Emgality. Providers must complete the prior authorization form and submit all required documentation before therapy is initiated.

Prior authorization required for Emgality
Complete and submit the Emgality prior authorization form

Documentation Required

Documentation of Prior Failure or Intolerance Required

The prior authorization form requires documentation that the patient has had a history of failure (after at least a two-month trial) or intolerance to listed therapies. Examples include: amitriptyline (Elavil) or venlafaxine (Effexor); divalproex sodium (Depakote/Depakote ER) or topiramate (Topamax); and at least one of the listed beta blockers (atenolol, propranolol, nadolol, timolol, metoprolol). Alternatively, documentation of contraindications to the specified agents may be required where indicated.

Form requires documentation of prior failure (>= 2 month trial) or intolerance to listed therapies
Listed therapies include: amitriptyline/venlafaxine; divalproex/topiramate; beta blockers (atenolol, propranolol, nadolol, timolol, metoprolol)
Documentation of contraindications to BOTH or ALL agents when applicable

Documentation Required

Form Fields and Required Attachments

The form includes required fields for member and provider information, medication details, prescriber signature, and may require attachments such as supporting clinical notes or prior medication trial documentation. Providers must ensure all fields are completed and necessary attachments are included.

Member and provider information (name, ID, NPI, contact, addresses, DOB)
Medication information (name, strength, dosage form, directions)
Prescriber signature and date; attachments may be required (clinical notes, trial documentation)

Denial Risk

Denial Risk for Incomplete Requests

This request may be denied unless all required information is received. Ensure the completed form and any requested supporting documentation are submitted to avoid denial.

Incomplete requests risk denial
Contact prior authorization at 855-811-2218 for assistance (Mon–Fri 8 a.m.–1 a.m. ET; Sat 9 a.m.–6 p.m. ET)

Background and Intended Use

This prior authorization form covers Emgality (galcanezumab) for prevention of migraine and for episodic cluster headache. For migraine the form distinguishes episodic migraine (defined as 4–14 migraine days per month and no more than 14 headache days per month) from chronic migraine (defined as ≥15 headache days per month with at least 8 migraine days per month for ≥3 months), and it asks whether medication overuse headache has been considered. For episodic cluster headache the form requires a history of at least two cluster periods lasting 7–365 days separated by pain‑free periods of at least three months. Reauthorization questions focus on documented clinical response (reduced frequency/intensity) and decreased use of acute migraine medications, with ongoing monitoring for medication overuse headache in chronic migraine.

OpenPayer

Emgality (galcanezumab) prior authorization

Coverage Criteria for Emgality (galcanezumab)

Diagnostic Frequency and Coding Definitions

Provider Requirements and Submission Instructions

Background and Intended Use

Definitions