Medication Prior Authorization Form — Migraine Prophylaxis (Aimovig)
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This form governs prior authorization requests for migraine prevention medications (specifically Aimovig is referenced) for Highmark Blue Shield members in North Carolina and collects member, provider, medication, and clinical information to determine coverage.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Initial Authorization Criteria
Coverage considered when ALL of the following are documented:
See form selection
Used to assess initial eligibility and reauthorization
Form asks if headaches are caused by medication overuse/rebound or lifestyle factors
Select all that apply on form
Form requires benefit/risk assessment if concurrent use is planned
Reauthorization Criteria
Reauthorization covered when ANY of the following documented improvement criteria are met (form specifies thresholds):
Yes/No field on reauthorization section of form
Yes/No field on reauthorization section of form
The form requires explicit documentation that the member's headaches are not primarily due to medication rebound/overutilization or modifiable lifestyle factors. The form asks whether headaches are caused by medication overuse (defined on the form as taking narcotics or triptans exceeding more than 18 doses per month) or lifestyle contributors (for example, sleep patterns, caffeine use). A positive indication that headaches are caused by overuse or lifestyle factors implies the member may not meet coverage criteria unless those issues are addressed and documented.
For reauthorization requests, the form specifies that ongoing coverage depends on documented clinical response. If the member does not meet the required improvement thresholds indicated on the form, continued therapy may be considered not medically necessary. The reauthorization questions require the provider to confirm whether the member has experienced either a ≥50% reduction in monthly migraine days overall or, for episodic migraine, a reduction of at least 4 monthly migraine days. A “No” response to these items supports discontinuation of coverage absent other documented justification.
Response Thresholds and Coding Notes
Submission, Documentation, and Prior Authorization Steps
Submission and reauthorization requirements
Submit a separate prior authorization form for each medication; complete all required fields on the form and fax the completed form and all clinical documentation to 1-866-240-8123 (mail option provided on form).
- Submit a separate form for each medication.
- Fax the completed form and all clinical documentation to 1-866-240-8123 (or mail per form instructions).
- Print or type legibly in blue or black ink; prescribing physician should usually complete the form.
- Provide physician address (required for physician notification).
Prior therapeutic failures required
Document therapeutic failure or intolerance to one or more prior migraine preventive medication classes by selecting all applicable agents on the form.
- Indicate failure/intolerance to anti-epileptic drugs (e.g., topiramate, valproic acid, divalproex sodium, carbamazepine).
- Indicate failure/intolerance to beta-blockers (e.g., propranolol, timolol, metoprolol).
- Indicate failure/intolerance to calcium-channel blockers (e.g., verapamil, amlodipine).
- Indicate failure/intolerance to SNRIs (e.g., venlafaxine, duloxetine) and tricyclic antidepressants (e.g., amitriptyline, nortriptyline).
- Indicate failure/intolerance to Botox, alpha-agonists (e.g., clonidine, guanfacine), or ACE/ARB (e.g., lisinopril, candesartan), as applicable.
- Select Other and list additional prior preventive therapies if needed.
Required documentation to support prior authorization
Complete all required member, provider, medication, and clinical information fields on the form to support the prior authorization request.
- Member information: Subscriber ID, group number, member name, phone, DOB, address, state, ZIP (Chunk 1).
- Provider information: Physician name, NPI, phone, fax, address, city, state, ZIP, suite/building, physician signature and date (Chunk 2).
- Medication information: Drug name, strength, requested quantity, days supply (30/90/other), directions (Chunk 3).
- Clinical information: diagnosis (episodic or chronic migraine), baseline migraine days/month, medication overuse/rebound status, prior therapy failures, concurrent CGRP use, and for reauthorization the response (≥50% reduction or ≥4 day reduction for episodic) (Chunk 4).
- Fax the completed form and all clinical documentation to 1-866-240-8123 (Chunk 6).
Incomplete forms or missing documentation may result in denial
Incomplete forms or missing supporting clinical documentation may result in denial; the completed form plus all clinical records must be faxed to 1-866-240-8123.
- Ensure all sections are completed and legible (print/type in blue or black ink).
- Provide physician address and signature as required.
- Include documentation of prior preventive therapy failures and baseline migraine frequency to avoid denial.
Purpose and Scope
This prior authorization form is used to request coverage for migraine prophylaxis with agents such as Aimovig. It collects the member's diagnosis categorized as Episodic Migraine Prophylaxis (4–14 headache days per month) or Chronic Migraine Prophylaxis (15 or more headache days per month), baseline average migraine days per month prior to therapy, history of medication overuse or lifestyle contributors, and prior preventive therapy failures. The information is used to determine initial eligibility and to establish baseline frequency for later reauthorization assessments.
Key Definitions
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