Medication prior authorization form for Ajovy (migraine prophylaxis)
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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.
No material clinical or coverage changes in this revision.
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:
See form instructions and medication information fields
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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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The form asks whether the member's headaches are caused by medication rebound/overutilization or lifestyle factors. Identify and document these potential causes on the form, as they may affect the appropriateness of migraine preventive therapy with Ajovy and are required information for the clinical review.
Submission of a completed prior authorization form does not guarantee payment. Authorization does not guarantee payment, and services that are not medically indicated or that lack required clinical documentation may be denied. Ensure all required fields are complete and supporting records are included when faxing or mailing the form.
Provider Actions and Submission Requirements
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
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
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
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.
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