CurrentHighmark Blueshield NenyPolicy N/A

Medication Prior Authorization Form — Ajovy (fremanezumab) for Migraine Prevention

Form and requirements for prior authorization of Ajovy (fremanezumab) for migraine prophylaxis, used by providers submitting requests for Highmark BlueShield members in North Carolina.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMedication Prior Authorization Form — Ajovy (fremanezumab) for Migraine Prevention

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with required clinical information and supporting documentation; fax to 1-866-240-8123.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1medication per form

50%reauthorization reduction

4 daysepisodic response

1-866-240-8123fax to submit

Coverage Criteria

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Diagnosis: Provider selects episodic or chronic migraine diagnosis (or lists other diagnosis with ICD-10).

Episodic: 4-14 headache days/month; Chronic: ≥15 headache days/month, of which ≥8 are migraine days.

Baseline frequency: Provide average number of migraine days per month prior to starting Ajovy.

Used to determine episodic vs chronic per diagnosis selection on form.

Medication overuse assessment: Confirm whether headaches are caused by medication rebound/overutilization (e.g., narcotics or triptans >18 doses/month) or lifestyle factors.

If overuse present, documentation is required and may affect eligibility.

Prior preventive therapy: Document therapeutic failure or intolerance to one or more relevant preventive medication classes.

Includes anti-epileptic drugs, beta-blockers, calcium-channel blockers, SNRIs, tricyclic antidepressants, Botox, alpha-agonists, ACE inhibitors/ARBs, or other listed agents.

Continuation / Reauthorization

Covered for continuation when the following response is documented:

Clinical response for chronic migraine: Member has experienced at least a 50% reduction in number of migraine days per month compared to start of therapy.>=50% reduction

Form requests Yes/No response for reauthorization.

Clinical response for episodic migraine: For episodic migraine, member has experienced a reduction of at least 4 monthly migraine days since the start of therapy.>=4 day reduction

Form requests Yes/No response for reauthorization.

Concurrent Therapy

Concurrent use rules:

Concurrent CGRP use: Provider must indicate whether Ajovy will be used in combination with another CGRP inhibitor for acute use.

If yes, provider must state that the benefits of concurrent use outweigh the risks and provide justification (Yes/No and benefit-risk justification required on form).

Assess and document whether the member's headaches are attributable to medication overuse or modifiable lifestyle factors. The form asks specifically if headaches are due to medication rebound/overutilization (defined on the form as taking narcotics or triptans in excess of 18 doses per month) or lifestyle contributors (for example, sleep patterns or caffeine use). If medication overuse is present, this must be identified and addressed in the clinical record because overuse is an alternate cause of headache and may preclude coverage of migraine prophylaxis until appropriately managed.

Authorization of Ajovy requires submission of a completed prior authorization form, but authorization does not guarantee payment. Payment is subject to the member's eligibility and plan benefits at the time of claim adjudication; ensure the member is eligible and that the requested service is covered under the member's policy.

Coding

Diagnosis codes (general)ICD-10

Other

field for diagnosis and/or ICD-10 code

Drug identificationNDC

NDC	Drug name/strength/quantity fields (medication-specific)

Response thresholds for continuation

General continuation response>= 50% reduction in monthly migraine days compared to start of therapy

Episodic migraine response>= 4-day reduction in monthly migraine days since start of therapy

DocumentationForm includes Yes/No fields to indicate whether response criteria are met for reauthorization

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required — submit one completed Medication Prior Authorization Form per medication. Fax to 1-866-240-8123 or mail per form instructions. The prescribing physician (PCP or specialist) should, in most cases, complete and sign the form.

Submit one form per medication
Fax: 1-866-240-8123

Documentation Required

Document Prior Preventive Therapy Failures

Document prior preventive therapy failures or intolerances. The form must indicate therapeutic failure or intolerance to specified preventive migraine medication classes (e.g., anti-epileptic drugs, beta-blockers, calcium-channel blockers, SNRIs, tricyclic antidepressants, Botox, alpha-agonists, ACE inhibitors/ARBs) or list other relevant agents.

Anti-epileptic drugs (e.g., topiramate, valproic acid)
Beta-blockers (e.g., propranolol, metoprolol)
Calcium-channel blockers (e.g., verapamil, amlodipine)
SNRIs (e.g., venlafaxine, duloxetine)
Tricyclic antidepressants (e.g., amitriptyline)
Botox
Alpha-agonists (e.g., clonidine)
ACE inhibitors/ARBs (e.g., lisinopril, candesartan)
Other — specify

Note

Submission Requirements — Completed Form & Supporting Documentation

Submit the completed form with all required member and provider information, medication details, and supporting clinical documentation. Include: member name, subscriber ID and group number, DOB, contact info; physician name, NPI, phone, fax, full address, and physician signature/date; drug name, strength, quantity, days' supply, directions; and completed clinical fields (diagnosis, baseline migraine days, medication history, rationale for therapy, and reauthorization response if applicable).

Member information: name, subscriber ID, group number, DOB, phone, address
Provider information: physician name, NPI, phone, fax, full address, signature, date
Medication information: drug name, strength, quantity, days' supply, directions
Clinical information: diagnosis, average migraine days/month, cause of headaches, prior therapy failures/intolerances, concurrent CGRP use, reauthorization response

Denial Risk

Incomplete Form Risk — Provide All Required Information

Incomplete forms or missing required information may result in denial or delay. Be sure to complete all fields, provide the physician address (required for physician notification), and include all supporting clinical documentation. Failure to complete all information or provide the required physician address may lead to denial or delay.

Failure to complete all requested information may delay or deny the request
Physician address is required for notification
Include supporting clinical documentation to avoid processing delays

Initial Authorization Criteria

Initial Authorization

Required documentation: Diagnosis (episodic or chronic migraine or other with ICD-10), baseline average monthly migraine days, and assessment for medication overuse/lifestyle factors must be provided.

Form includes fields for diagnosis selection, baseline days per month, and overuse assessment.

Prior preventive therapy failures/intolerances: Document therapeutic failure or intolerance to applicable preventive medication classes before initiating Ajovy.

Includes anti-epileptics, beta-blockers, calcium-channel blockers, SNRIs, tricyclics, Botox, alpha-agonists, ACE inhibitors/ARBs, or other agents listed on the form.

Form completion requirements: Submit a separate, fully completed form for this medication with physician address and required provider signature; fax or mail as instructed.

Incomplete forms or missing physician address may lead to denial or delay; fax to 1-866-240-8123.

Reauthorization / Continuation Criteria

Reauthorization

Documented clinical improvement: Provider must document clinical improvement since therapy start: either ≥50% reduction in monthly migraine days (chronic) or ≥4-day reduction (episodic).see criteria

Form includes Yes/No fields for these response thresholds; authorization for continuation is contingent on meeting the applicable threshold.

Step Therapy

Step	Requirement
1	Provider must document therapeutic failure or intolerance to one or more of the following preventive medication classes: anti-epileptic drugs (e.g., topiramate, valproic acid, divalproex sodium, carbamazepine), beta-blockers (e.g., propranolol, timolol, metoprolol), calcium-channel blockers (e.g., verapamil, amlodipine), serotonin–norepinephrine reuptake inhibitors (e.g., venlafaxine, duloxetine), tricyclic antidepressants (e.g., amitriptyline, nortriptyline), Botox, alpha-agonists (e.g., clonidine, guanfacine), ACE inhibitors/angiotensin II receptor blockers (e.g., lisinopril, candesartan), or other listed agents.

Step

Requirement

Provider must document therapeutic failure or intolerance to one or more of the following preventive medication classes: anti-epileptic drugs (e.g., topiramate, valproic acid, divalproex sodium, carbamazepine), beta-blockers (e.g., propranolol, timolol, metoprolol), calcium-channel blockers (e.g., verapamil, amlodipine), serotonin–norepinephrine reuptake inhibitors (e.g., venlafaxine, duloxetine), tricyclic antidepressants (e.g., amitriptyline, nortriptyline), Botox, alpha-agonists (e.g., clonidine, guanfacine), ACE inhibitors/angiotensin II receptor blockers (e.g., lisinopril, candesartan), or other listed agents.

Site of Care

Note

Site-of-care note — medication strength, directions, and supply requested

The form requests medication strength, directions, and the requested supply (30 days, 90 days, or other); no specific site-of-care restriction is stated on the form.

Medication fields: drug name, drug strength, requested quantity, requested supply day (30 days, 90 days, other), directions.

Definitions

Episodic migraine — definition

Episodic migraine definition4-14 headache days per month

Diagnostic selectionForm asks provider to select Episodic Migraine Prophylaxis when 4-14 headache days/month

Use in coverage determinationBaseline average monthly headache days is collected to determine episodic vs chronic categorization

Chronic migraine — definition

Chronic migraine definition15 or more headache days per month, of which 8 or more are migraine days

Diagnostic selectionForm asks provider to select Chronic Migraine Prophylaxis when criteria of 15+ headache days/month with >=8 migraine days are met

Baseline assessmentAverage number of migraine days per month prior to starting Ajovy is collected to confirm chronic migraine

Background

Ajovy (fremanezumab) is a monoclonal antibody indicated for migraine prophylaxis in both episodic migraine (4–14 headache days per month) and chronic migraine (≥15 headache days per month, of which ≥8 are migraine days). The prior authorization form is used to collect baseline migraine frequency, confirm the appropriate diagnosis, assess for medication overuse or lifestyle contributors to headache, document prior preventive therapy failures or intolerances, and capture response data for reauthorization. For initial requests the form asks for the average number of migraine days per month prior to starting Ajovy; for reauthorization the form documents clinical response, including a required ≥50% reduction in monthly migraine days for chronic migraine or a ≥4-day reduction in monthly migraine days for episodic migraine.