CurrentHighmark PennsylvaniaPolicy N/A

Medication prior authorization form for Ajovy (migraine prophylaxis)

This document is a medication prior authorization (PA) form used by Highmark Pennsylvania to collect member, provider, clinical, and treatment information to request coverage for Ajovy for migraine prevention. It affects prescribing physicians and members seeking authorization for the medication.

Policy Summary

PayerHighmark Pennsylvania

PolicyMedication prior authorization form for Ajovy (migraine prophylaxis)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the Ajovy prior authorization form with required clinical documentation to 1-866-240-8123.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8number of numbered clinical questions/sections on the form

30/90day supply options provided

2migraine frequency categories captured

Coverage Criteria for Ajovy (migraine prevention)

Form completion and clinical response requirements

Covered when ALL of the following required form fields and clinical response criteria are documented:

Policy Summary

PayerHighmark Pennsylvania

PolicyMedication prior authorization form for Ajovy (migraine prophylaxis)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the Ajovy prior authorization form with required clinical documentation to 1-866-240-8123.

SourceLink

On This Page

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Complete required form fields: Provider must complete member information, provider information, medication information (name, strength, quantity, day supply, directions) and the clinical information section of the Ajovy prior authorization form.

See form instructions and medication information fields

Diagnosis and baseline migraine frequency: Select and document diagnosis as Episodic Migraine Prophylaxis (4-14 headache days per month) OR Chronic Migraine Prophylaxis (15 or more headache days per month, of which 8 or more are migraine days). Provide the member's average migraine days per month prior to starting Ajovy and record the member's weight (with units).episodic 4-14 days; chronic >=15 days with >=8 migraine days

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Assessment for secondary causes: Document whether headaches are caused by medication rebound/overutilization or lifestyle factors (Yes/No).

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Prior preventive therapy trials: Indicate therapeutic failure or intolerance to one or more listed preventive therapies (anti-epileptic drugs, beta-blockers, calcium-channel blockers, SNRIs, tricyclic antidepressants, Botox, alpha-agonists, ACE inhibitors/ARBs, or other specified agents).documented failure or intolerance

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Concomitant CGRP agent assessment: If Ajovy will be used concurrently with another CGRP agent for acute use (for example, Nurtec ODT, Ubrelvy), document Yes/No and, if yes, attest that the benefits of concurrent therapy outweigh the risks.attestation required if concurrent use

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Response criteria for continuation of therapy

50% responder threshold: At least a 50% reduction in the number of migraine days per month compared to start of therapy.>=50% reduction
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Episodic migraine response: For members with episodic migraine, a reduction of at least 4 monthly migraine days since start of therapy.>=4 fewer monthly migraine days
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Chronic migraine response: For members with chronic migraine, a reduction of at least 5 monthly migraine days since start of therapy.>=5 fewer monthly migraine days
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Attestation and additional information: Provide any additional pertinent clinical information and certify that the information is true, accurate, and complete; note that payment is subject to member eligibility and authorization does not guarantee payment.

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Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Ajovy. The provider must complete and submit the Ajovy prior authorization form with the member, provider, medication, and clinical information to request coverage.

Submit a separate form for each medication
Form must include member diagnosis, weight, migraine frequency, and medication details (name, strength, quantity, day supply, directions)
Fax: 1-866-240-8123 or mail per form instructions

Documentation Required

Document Therapeutic Failure or Intolerance

The form asks whether the member has experienced therapeutic failure or intolerance to listed preventive therapies. Providers must indicate ALL applicable prior trials (anti-epileptic drugs, beta-blockers, calcium-channel blockers, SNRIs, tricyclic antidepressants, Botox, alpha-agonists, ACE inhibitors/ARBs, or other).

List specific agents tried where applicable (examples provided on form: topiramate, valproic acid, propranolol, verapamil, venlafaxine, amitriptyline, etc.)
Provide details of intolerance or inadequate response

Denial Risk

Risk of Delay or Denial for Incomplete/Illegible Forms

Incomplete or illegible forms or missing required documentation (including physician address and clinical records) may delay review or lead to denial. Ensure all questions are answered and handwriting is legible (use blue or black ink or type).

Complete ALL information on the form
Prescribing physician (PCP or Specialist) should usually complete the form
Illegible entries or missing clinical documentation risk delay or denial

Note

Submission Channels and Contact Details

Submission channels and contact details: fax the completed form and all clinical documentation to 1-866-240-8123 or mail per the form instructions. Provide the physician address on the form as it is required for physician notification.

Fax: 1-866-240-8123
Mail: follow mailing address instructions on the form
Include physician address for notification

Background

This form is used to request coverage for Ajovy, a calcitonin gene-related peptide (CGRP) monoclonal antibody, for migraine prevention. It captures the diagnosis category—episodic migraine (4–14 headache days/month) or chronic migraine (≥15 headache days/month with ≥8 migraine days)—and requests the member's average migraine days per month prior to starting Ajovy to establish baseline frequency. Use the form to document prior preventive therapy trials, weight, and response to therapy where applicable to support the authorization request.