CurrentUnitedHealthcarePolicy N/A

Step therapy for CGRP antagonist migraine preventives

Defines UnitedHealthcare step therapy requirements for coverage of Aimovig (erenumab), Ajovy (fremanezumab), and Emgality (galcanezumab) for migraine and related indications; affects providers submitting prior authorization for these medications.

Policy Summary

PayerUnitedHealthcare

PolicyStep therapy for CGRP antagonist migraine preventives

Policy CodePolicy N/A

Change TypeMaterial clinical revisions and indication/strength updates

Effective Date4/1/2026

Next Review DateN/A

Key ActionDocument prior prophylactic therapy trials (name and date tried) and obtain prior authorization; approvals issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

Background section updated with pediatric information for Ajovy and a bypass for pediatric patients was added.

Removed Nurtec and Qulipta as options for Ajovy and added oral CGRPs to required options for Ajovy in prior revisions.

Added the episodic cluster headache indication and included approvable strength for Emgality (100 mg and 120 mg specified).

2026-04-01Program effective date

12 monthsAuthorization duration

2 monthsMin trial length per therapy

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Coverage Criteria for CGRP Antagonist Migraine Preventives

Initial approval for Aimovig or Emgality (120 mg)

Covered when ALL of the following are met

Aimovig/Emgality (120 mg) general criteria: Failure (after a trial of at least two months), contraindication, or intolerance to two of the following prophylactic therapies (document name and date tried): one beta-blocker (atenolol, metoprolol, nadolol, propranolol, or timolol); candesartan; divalproex sodium; onabotulinumtoxinA; an SNRI (duloxetine or venlafaxine); topiramate; or a tricyclic antidepressant (amitriptyline or nortriptyline).two therapies; >=2 months each

OnabotulinumtoxinA (Botox) coverage may be subject to additional benefit and coverage review requirements.

Ajovy (fremanezumab) approval

Ajovy will be approved when BOTH of the following criteria are met

Step 1 - alternative prophylactic trials: Failure (after a trial of at least two months), contraindication, or intolerance to two prophylactic therapies from the specified list (document name and date tried): one beta-blocker (atenolol, metoprolol, nadolol, propranolol, or timolol); candesartan; divalproex sodium; onabotulinumtoxinA; an SNRI (duloxetine or venlafaxine); topiramate; or a tricyclic antidepressant (amitriptyline or nortriptyline).two therapies; >=2 months each

Provider must document name and date tried. Ajovy is typically excluded from benefit coverage; approval requires meeting the criteria below or applicable attestation.

Step 2 - prior CGRP trials or pediatric bypass: Either: (a) Failure (after a trial of at least three months) or contraindication/intolerance to both Aimovig and Emgality (120 mg), OR (b) provider attests that Aimovig and Emgality are not options due to age less than 18.three months for Aimovig/Emgality trials; age <18 for bypass

Document dates tried for Aimovig and Emgality when pathway (a) is used.

Emgality (100 mg) approval

Emgality 100 mg strength approval

Emgality 100 mg strength will be approved as indicated (approved for episodic cluster headache in adults).

Authorization will be issued for 12 months; state mandates may modify trial lengths or other requirements.

For members in California business, a trial of non‑CGRP preventive treatments will not be required prior to authorization. For members in Connecticut, Kentucky, and Mississippi, the policy requires only a 30‑day trial of the specified alternative prophylactic therapies rather than the standard two‑month trial. These state‑specific allowances do not remove other applicable federal or plan‑level requirements; any state mandates and member benefit plan provisions still apply.

The policy notes that Ajovy (fremanezumab) is typically excluded from benefit coverage. Where Ajovy is considered, approval follows the policy’s step‑therapy requirements and any applicable state or plan mandates; providers should assume Ajovy is not covered unless an exception or prior authorization approval is documented.

Operationally, UnitedHealthcare may grant initial authorization or reauthorization based solely on prior claims or medication history and diagnosis codes (ICD‑10), regardless of the written coverage criteria. This means that when the member’s claims record demonstrates prior use of required therapies and the diagnosis aligns with the policy, the plan’s automated or programmatic approval processes may be used to approve therapy without additional documentation. Authorization durations remain 12 months, and state mandates or member‑specific benefit language may still modify application of this allowance.

Provider Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Providers must document trials, contraindications, or intolerances to required lower-cost migraine preventive therapies. Authorization will be issued for 12 months. State mandates, federal requirements, member benefit plan coverage, and other utilization management programs may affect coverage.

Prior authorization required for Aimovig, Ajovy, and Emgality (per program)
Authorization duration: 12 months

Step Therapy

Step Therapy Requirements

Step therapy requires a documented trial of lower-cost migraine preventive medications prior to coverage of Aimovig, Ajovy, or Emgality. The required agents include beta-blockers (atenolol, metoprolol, nadolol, propranolol, timolol), candesartan, divalproex sodium, onabotulinumtoxinA (Botox) (may have separate coverage rules), SNRIs (duloxetine, venlafaxine), topiramate, and tricyclic antidepressants (amitriptyline, nortriptyline). Ajovy also requires failure of Aimovig and Emgality (120 mg) or provider attestation that those are not options for patients under 18.

Definitions

CGRP antagonist

DefinitionCalcitonin gene-related peptide (CGRP) receptor antagonists used for prevention of migraine: Aimovig (erenumab), Ajovy (fremanezumab), and Emgality (galcanezumab).

Indication contextThese agents are indicated for preventive treatment of migraine in adults.

Program impactSubject to step therapy requiring trial of lower-cost migraine preventive medications prior to coverage.

Pediatric noteAjovy has a pediatric preventive indication for ages 6–17 years who weigh ≥45 kg (program includes an age-based attestation pathway).

Emgality 100 mg

Approved strength and indicationEmgality 100 mg is an approved strength indicated for the treatment of episodic cluster headache in adults.

Background

Aimovig (erenumab), Ajovy (fremanezumab) and Emgality (galcanezumab) are calcitonin gene‑related peptide (CGRP) receptor antagonists indicated for preventive treatment of migraine in adults. Emgality additionally has a 100 mg strength that is indicated for the treatment of episodic cluster headache in adults. The policy’s step‑therapy framework is intended to encourage use of lower‑cost preventive options before these CGRP‑targeting agents; approval periods for authorized CGRP therapies are issued for 12 months and state‑specific mandates may alter required prior‑trial lengths.

Policy Revision History

2026-01background updateLatest

Background section updated with pediatric information for Ajovy and an age-based pediatric bypass allowing provider attestation that Aimovig and Emgality are not options for patients under 18.

2025-02criteria revision

Updated list of potential prophylactic therapies, added oral CGRPs to the required options for Ajovy, and added a California-specific footnote for state requirements.

2024-03annual review