CurrentMass General Brigham Health PlanPolicy N/A

Prophylactic Treatment of Migraines — Injectable CGRP Inhibitors (Aimovig, Emgality)

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Defines prior authorization, pharmacy benefit coverage, clinical criteria, and quantity limits for Aimovig (erenumab) and Emgality (galcanezumab) for migraine prevention and episodic cluster headache in adult commercial/exchange members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyProphylactic Treatment of Migraines — Injectable CGRP Inhibitors (Aimovig, Emgality)

Policy CodePolicy N/A

Change TypeOperational revisions and clarifications

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateJul 1, 2026

Key ActionSubmit prior authorization under the pharmacy benefit with medical records showing age ≥18, ≥4 migraine days/month, and trials of two different prophylactic agents.

SourceLink

POLICY UPDATE CHANGES

Policy updated to indicate it no longer applies to the medical benefit and removed Vyepti from the policy.

Removed Ajovy from the policy as agent is moving to nonformulary status.

Reauthorization verbiage updated from 'documentation' to 'submission of medical records (e.g., chart notes).'

≥4migraine days/month threshold

2required prior trials

18+

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CurrentMass General Brigham Health PlanPolicy N/A

Prophylactic Treatment of Migraines — Injectable CGRP Inhibitors (Aimovig, Emgality)

Customize your policy alerts

Sign up for all Mass General Brigham Health Plan policy alerts

Know when Mass General Brigham Health Plan releases new policies or updates existing guidance.

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Policy Summary

PayerMass General Brigham Health Plan

PolicyProphylactic Treatment of Migraines — Injectable CGRP Inhibitors (Aimovig, Emgality)

Policy CodePolicy N/A

Change TypeOperational revisions and clarifications

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateJul 1, 2026

Key ActionSubmit prior authorization under the pharmacy benefit with medical records showing age ≥18, ≥4 migraine days/month, and trials of two different prophylactic agents.

SourceLink

POLICY UPDATE CHANGES

Policy updated to indicate it no longer applies to the medical benefit and removed Vyepti from the policy.

Removed Ajovy from the policy as agent is moving to nonformulary status.

Reauthorization verbiage updated from 'documentation' to 'submission of medical records (e.g., chart notes).'

≥4migraine days/month threshold

2required prior trials

18+

Coverage and Medical Necessity Criteria

inv-01: Prophylactic migraine authorization criteria

Covered when ALL of the following are met:

ALL of the following

Member is 18 years of age or older
Requested medication is being used for prophylactic treatment of migraines
Member has been experiencing at least 4 migraine days per month
Member has had an inadequate response to a trial of at least TWO different prophylactic migraine medications, each with a different mechanism of action, each tried for at least 60 days within the past 3 years; both trials must be from Level A or Level B categories per the American Academy of Neurology guidelines
Requested medication will not be used in combination with another CGRP inhibitor for the preventive treatment of migraines
Note: Triptans will not be considered prophylactic options
Operational: triptans are excluded from prophylactic trial consideration

(For new-to-plan members with ≤90 days of prior coverage) Submit medical records documenting current treatment as part of prior authorization documentation

See provider actions for documentation requirements

inv-02: Episodic cluster headache criteria

Covered when ALL of the following are met for Emgality (episodic cluster headache):

ALL of the following

Member has a diagnosis of episodic cluster headaches
Member is 18 years of age or older
Member has experienced at least 5 episodes of cluster headaches within the past 12 months

Emgality for episodic cluster headache is covered per the dosing and quantity limits specified in the policy

inv-03: Continuation, limits, and dosing

Continuation, quantity limits, and authorization durations:

ALL of the following

Reauthorization requires submission of medical records (e.g., chart notes) documenting improvement as evidenced by a decrease in frequency and severity of migraines or cluster headaches

Initial approvals will be granted for 3 months

Reauthorizations will be granted for 12 months

ALL of the following

Aimovig 70 mg: 1 pen per 30 days
Aimovig 140 mg: 1 pen per 30 days

Drugs, Dosing, and Coding

Covered drugs and dosingmixedCovered

erenumab-aooe (Aimovig)	Aimovig injectable CGRP receptor antagonist; dosing 70 mg once monthly; some patients may benefit from 140 mg once monthly
galcanezumab-gnlm (Emgality)	Emgality injectable CGRP ligand antibody; dosing for migraine: 240 mg loading dose followed by 120 mg monthly; dosing for cluster headache: 300 mg initially at onset of cluster period then monthly until end of cluster period

inv-05: Minimum age

Minimum age18 years

Applies to indicationsAdults for prophylactic migraine and episodic cluster headache

Source guidancePolicy requires member to be 18 years of age or older

inv-06: Minimum migraine days per month

Minimum migraine days per month≥4 migraine days per month

Measurement periodReported as ongoing monthly frequency for prophylactic eligibility

Not a standalone criterion

Prior Authorization, Documentation, and Operational Rules

Prior Authorization

Prior authorization and documentation requirements

Prior authorization is required under the pharmacy benefit for commercial/exchange members; these products are designated specialty and must be filled at a contracted specialty pharmacy. If the member is new to the plan (coverage effective ≤ 90 days), submit medical records documenting the member is currently receiving the requested drug. Authorization criteria include: member age ≥ 18, use for prophylactic migraine, ≥ 4 migraine days per month, trial and inadequate response to at least two different prophylactic migraine medications with different mechanisms (each tried ≥ 60 days within the past 3 years) and both trials must be Level A or B per AAN, and the requested medication will not be used in combination with another CGRP inhibitor. For reauthorization, submit medical records (e.g., chart notes) documenting improvement (decrease in frequency and severity).

Specialty pharmacy dispensing required (designated specialty).
New-to-plan (≤ 90 days) requires submission of medical records documenting current treatment.
Clinical prior authorization criteria: age ≥18; prophylactic migraine indication; ≥4 migraine days/month; ≥2 distinct prophylactic medication trials (different mechanisms), each ≥60 days within past 3 years, both Level A/B per AAN; not to be combined with another CGRP inhibitor.
Reauthorization requires submission of medical records showing improvement (decreased frequency/severity).

Definitions and Guideline References

inv-10: Calcitonin gene-related peptide (CGRP) antagonist

DefinitionCalcitonin gene-related peptide (CGRP) antagonist — monoclonal antibodies targeting the CGRP pathway for migraine prevention (e.g., Aimovig, Emgality)

Products referencedAimovig (erenumab-aooe) and Emgality (galcanezumab-gnlm)

Indications notedPreventive treatment of migraine; Emgality also indicated for episodic cluster headache

inv-11: AAN Level A/B agents

AAN Level A/B requirementPrior trials: at least TWO different prophylactic medications from AAN Level A or B categories, each tried ≥60 days within the past 3 years

Examples (Level A)Divalproex sodium, sodium valproate, topiramate, metoprolol, propranolol, timolol