Medication Prior Authorization Form — Ajovy (fremanezumab) for Migraine Prevention
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Form and requirements for prior authorization of Ajovy (fremanezumab) for migraine prophylaxis, used by providers submitting requests for Highmark BlueShield members in North Carolina.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy
Covered when ALL of the following are met:
Episodic: 4-14 headache days/month; Chronic: ≥15 headache days/month, of which ≥8 are migraine days.
Used to determine episodic vs chronic per diagnosis selection on form.
If overuse present, documentation is required and may affect eligibility.
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:
Form requests Yes/No response for reauthorization.
Form requests Yes/No response for reauthorization.
Concurrent Therapy
Concurrent use rules:
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
| Other | field for diagnosis and/or ICD-10 code |
| NDC | Drug name/strength/quantity fields (medication-specific) |
Provider Actions & Submission Requirements
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
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
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
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
Initial Authorization
Form includes fields for diagnosis selection, baseline days per month, and overuse assessment.
Includes anti-epileptics, beta-blockers, calcium-channel blockers, SNRIs, tricyclics, Botox, alpha-agonists, ACE inhibitors/ARBs, or other agents listed on the form.
Incomplete forms or missing physician address may lead to denial or delay; fax to 1-866-240-8123.
Reauthorization / Continuation Criteria
Reauthorization
Reauthorization
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. |
Quantity Limits
Site of Care
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
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.
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