CurrentCignaPolicy N/A

Prior authorization form for CGRP and related migraine medications

This document is a Cigna prior authorization form used by prescribers to request coverage for injectable migraine and cluster headache therapies (Aimovig, Ajovy, Emgality and others) and documents clinical history, prior treatments, and dispensing site; it affects prescribers and Cigna pharmacy reviewers.

Policy Summary

PayerCigna

PolicyPrior authorization form for CGRP and related migraine medications

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form with all asterisked items, prescriber attestation, and signature to document prior trials, dosing, indication, and rationale.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

1urgent request phone

v070120version

Coverage Criteria

Information required to assess medical necessity

Coverage evaluation will consider documentation of ALL of the following as applicable:

Prescriber and patient identification: Asterisked prescriber and patient identifiers completed and prescriber attestation signed.

Incomplete completion of asterisked (*) items will prevent Cigna from responding via fax with the outcome of the review.

Medication selection and indication: Requested medication selected with dose and indication noted (preventative migraine or cluster headache).

Form includes specific choices for Aimovig, Ajovy, Emgality and other specified formulations and asks whether request is new start or continuation with response documented for continued therapy.

Prior headache/migraine frequency: Documentation of baseline headache days per month and baseline migraine days per month prior to the requested drug.

Policy Summary

PayerCigna

PolicyPrior authorization form for CGRP and related migraine medications

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form with all asterisked items, prescriber attestation, and signature to document prior trials, dosing, indication, and rationale.

SourceLink

On This Page

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Form explicitly asks prior number of headache and migraine days per month.

Step therapy / alternative agent considerations: If requesting Ajovy or Emgality for migraine, documentation whether patient has tried Aimovig and details of trial; if not tried, documentation of inability or contraindication to try Aimovig.

Form queries prior use of Aimovig when requesting alternative CGRP inhibitors and requests reasons if Aimovig was not tried.

Cluster headache specific requirements: If request is for cluster headache (Emgality), documentation of cluster frequency and trials and/or contraindications to injectable sumatriptan and zolmitriptan nasal spray as applicable, with dates, durations and outcomes.

Cluster headache is defined on the form as occurring between one headache every other day and eight headaches per day.

Concurrent therapy considerations: Documentation whether patient will receive other CGRP inhibitors or Botox during the same time period and clinical rationale for concurrent use if yes.

Form asks clinicians to explain rationale for concurrent CGRP inhibitor use and documents concurrent Botox use; for chronic migraine the form ties continued symptoms to adequacy of Botox or CGRP trials.

Provider attestation and additional information: Completed prior authorization form including clinical rationale, pertinent history, and prescriber attestation/signature.

Form requests additional pertinent information such as clinical rationale, alternatives tried, intolerances/adverse reactions and requires prescriber attestation.

The form asks the prescriber to indicate whether the requested medication will be used as preventative treatment of migraine or for cluster headache. When the request is not for preventative migraine, the form requests the diagnosis related to use. Selection of indication on the form documents the intended use but does not itself authorize use outside those specified indications.

The form specifically asks whether the patient will receive any other CGRP inhibitors indicated for migraine prevention during the same period and, if yes, requires the prescriber to provide a clinical rationale for concurrent use. Failure to document appropriate rationale or to address concurrent therapy on the form may affect coverage decisions.

Requested Medication and Coding

Requested medication optionsmixed

Aimovig 70mg	listed medication option on form
Aimovig 140mg	listed medication option on form
Ajovy 225mg	listed medication option on form
Ajovy 225mg/1.5ml autoinjector	listed medication option on form
Emgality 100mg syringe	listed medication option on form
Emgality 120mg pen	listed medication option on form
Emgality 120mg syringe	listed medication option on form

Botox trial duration for chronic migraine

Minimum durationMinimum 6 month trial (2 injection cycles) of Botox is required for chronic migraine before indicating continued migraines

ApplicabilityThis duration applies when the requested drug is being used for preventative treatment of chronic migraine and Botox was used as a prior therapy

Form evidence requiredForm asks whether patient continued to experience ≥4 migraine days/month after the Botox trial

CGRP inhibitor trial duration referenced

Minimum durationMinimum 3 month trial of a CGRP inhibitor (Aimovig, Ajovy, Emgality, or Vyepti) is referenced for chronic migraine

ApplicabilityApplies when the requested drug is for preventative treatment of chronic migraine and prior CGRP therapy was tried

Form evidence requiredForm asks whether patient continued to experience ≥4 migraine days/month after the CGRP trial

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for specified CGRP inhibitors and formulations. Complete and submit the Cigna prior authorization form with all requested patient and prescriber identifiers, selected medication and dosing, indication, and relevant clinical history.

Complete the prior authorization form for specified CGRP inhibitors (Aimovig, Ajovy, Emgality, Vyepti) and selected formulations.
Include patient identifiers (Cigna ID, DOB, address) and prescriber identifiers (DEA, NPI or TIN, specialty, office contact).

Documentation Required

Document Prior Trials (including Botox)

The form documents prior trials including Botox and specified oral preventive medication classes. For chronic migraine requests, the form asks whether the patient continued to experience ≥4 migraine days/month after trials with Botox (minimum 6 months/2 injection cycles) or a minimum 3-month trial of another CGRP inhibitor (Aimovig, Ajovy, Emgality, or Vyepti).

Document prior trials with Botox and oral preventive medication classes (antiepileptics such as divalproex, topiramate; antidepressants such as amitriptyline, venlafaxine; beta blockers such as metoprolol, propranolol, timolol).
If prior therapy tried, include drug name, strength, dates taken, duration, and documented results (response, intolerance, adverse reactions).

Documentation Required

Submission Completeness — New vs Continued Therapy

A completed prior authorization form must indicate whether the request is a new start or continuation of therapy and, for continuations, report clinical benefit (reduction in monthly migraine days/hours and days requiring acute migraine-specific treatment).

Select new start of therapy or continued therapy on the form.
For continued therapy, indicate whether there was a reduction in monthly migraine days/hours and reduction in days requiring acute migraine-specific treatment.

Documentation Required

Complete All Asterisked Items

Due to privacy regulations, all asterisked (*) items on the form must be completed. Incomplete completion of required asterisked items will prevent Cigna from responding via fax with the outcome of the review.

Ensure all asterisked (*) patient and prescriber fields are fully completed (e.g., Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, Date of Birth, Patient Street Address).

Background

This prior authorization form collects clinical information to support use of CGRP monoclonal antibodies (examples listed on the form include Aimovig, Ajovy, Emgality) for either prevention of migraine or treatment of cluster headache. It captures baseline headache and migraine days per month, the requested medication and dosing, whether the request is a new start or continuation and response to therapy, prior preventive medication trials (including Botox and specific oral classes) with dates and outcomes, documentation of contraindications or inability to use alternatives, and any concurrent use of Botox or other CGRP inhibitors along with clinical rationale.

Definitions

Cluster headache (as used in form)

DefinitionCluster headache is defined on the form as occurring with a frequency between one headache every other day and eight headaches per day.

Question contextForm asks specifically if Emgality is being used for treatment of cluster headache using this frequency definition.

Related checkboxProvider must indicate Yes/No whether the drug is being used for cluster headache when applicable.