Pharmacy Prior Authorization Criteria

CGRP Inhibitors - PA, NF

Indications for Prior Authorization

Aimovig (erenumab-aooe), Ajovy (fremanezumab-vfrm), Vyepti (eptinezumab-jjmr); Qulipta (atogepant)

For diagnosis of Preventive Treatment of Migraine
Indicated for the preventive treatment of migraine in adults.

Emgality (galcanezumab-gnlm)

For diagnosis of Preventive Treatment of Migraine
Indicated for the preventive treatment of migraine in adults.
For diagnosis of Episodic Cluster Headache
Indicated for the treatment of episodic cluster headache in adults.

Nurtec ODT (rimegepant)

For diagnosis of Acute Treatment of Migraine
Indicated for the acute treatment of migraine with or without aura in adults.
For diagnosis of Preventive Treatment of Episodic Migraine
Indicated for the preventive treatment of episodic migraine in adults.

Ubrelvy (ubrogepant), Zavzpret (zavegepant)

For diagnosis of Acute Treatment of Migraine
Indicated for the acute treatment of migraine with or without aura in adults.
Limitations of Use: Ubrelvy AND Zavzpret are not indicated for the preventive treatment of migraine.

Criteria

Aimovig or Ajovy

Prior Authorization (Initial Authorization)

Length of Approval: 6 Months [E]
For diagnosis of Preventive Treatment of Migraine

One of the following:

Both of the following:

Diagnosis of episodic migraines

AND

Patient has greater than or equal to 4 migraine days per month [A, B, C]

All of the following:

Diagnosis of chronic migraines

AND

Patient has greater than or equal to 8 migraine days per month [A]

AND

Medication overuse headache has been considered and potentially offending medication(s) have been discontinued [H]

AND

Patient is 18 years of age or older [I]

AND

History of failure (after at least a two month trial), contraindication or intolerance to TWO of the following preventive treatments for migraine from different mechanisms of action [D, E, F, G, 10]:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Aimovig or Ajovy

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Preventive Treatment of Migraine

Patient has experienced a positive response to therapy (e.g., a reduction in headache frequency and/or intensity, a reduction in the number of workdays missed due to migraines)

AND

Use of acute migraine medications [e.g., nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen), triptans (e.g., eletriptan, rizatriptan, sumatriptan)] has decreased since the start of CGRP therapy

AND

For Chronic Migraine only: Patient continues to be monitored for medication overuse headache (MOH) [H]

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Emgality 120 mg/mL

*QL Override for Emgality (For new starts only): For migraine, please enter 2 PAs with the same start date as follows: First PA: Approve two pens or syringes per 30 days for 1 month with a fill count of 2 (Loading dose has a MDD of 0.067); Second PA: Approve one pen or syringe per 30 days (no overrides needed) for 6 months. (Emgality 120 mg/mL is hard-coded with a quantity of one prefilled pen/syringe per 30 days)

Prior Authorization (Initial Authorization)

Length of Approval: 6 months [E]
For diagnosis of Preventive Treatment of Migraine

One of the following:

Both of the following:

Diagnosis of episodic migraines

AND

Patient has greater than or equal to 4 migraine days per month [A, B, C]

All of the following:

Diagnosis of chronic migraines

AND

Patient has greater than or equal to 8 migraine days per month [A]

AND

Medication overuse headache has been considered and potentially offending medication(s) have been discontinued [H]

AND

Patient is 18 years of age or older [I]

AND

History of failure (after at least a two month trial), contraindication, or intolerance to TWO of the following preventive treatments for migraine from different mechanisms of action [D, E, F, G, 10]:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Trial and failure, contraindication, or intolerance to BOTH of the following:

Aimovig
Ajovy

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Emgality 120 mg/mL

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Preventive Treatment of Migraine

Patient has experienced a positive response to therapy (e.g., a reduction in headache frequency and/or intensity, a reduction in the number of workdays missed due to migraines)

AND

Use of acute migraine medications [e.g., nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen), triptans (e.g., eletriptan, rizatriptan, sumatriptan)] has decreased since the start of CGRP therapy

AND

For Chronic Migraine only: Patient continues to be monitored for medication overuse headache (MOH) [H]

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

AND

Trial and failure, contraindication, or intolerance to BOTH of the following:

Aimovig
Ajovy

Emgality 120 mg/mL

*QL Override for Emgality (For new starts only): For migraine, please enter 2 PAs with the same start date as follows: First PA: Approve two pens or syringes per 30 days for 1 month with a fill count of 2 (Loading dose has a MDD of 0.066); Second PA: Approve one pen or syringe per 30 days (no overrides needed) for 6 months. (Emgality 120 mg/mL is hard-coded with a quantity of one prefilled pen/syringe per 30 days)

Non Formulary

Length of Approval: 6 months [E]
For diagnosis of Preventive Treatment of Migraine

One of the following:

Both of the following:

Submission of medical records (e.g., chart notes) confirming a diagnosis of episodic migraines

AND

Submission of medical records (e.g., chart notes) confirming the patient has greater than or equal to 4 migraine days per month [A, B, C]

All of the following:

Submission of medical records (e.g., chart notes) confirming a diagnosis of chronic migraines

AND

Submission of medical records (e.g., chart notes) confirming the patient has greater than or equal to 8 migraine days per month [A]

AND

Medication overuse headache has been considered and potentially offending medication(s) have been discontinued [H]

AND

Patient is 18 years of age or older [I]

AND

Paid claims or submission of medical records (e.g., chart notes) confirming history of failure (after at least a two month trial), contraindication, or intolerance to TWO of the following preventive treatments for migraine from different mechanisms of action [D, E, F, G, 10]:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Both of the following:

Submission of medical records (e.g., chart notes) confirming a history of failure after at least a 12 week trial to BOTH of the following (unless there is a contraindication or intolerance):

Aimovig
Ajovy

AND

Submission of medical records (e.g., chart notes) confirming a history of failure after at least an 8 week trial to ONE of the following (unless there is a contraindication or intolerance):

Nurtec
Qulipta

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Nurtec ODT

Note: For use for preventive treatment of migraine, please enter a quality limit override of #16 tablets per 30 days (MDD, 0.54) for 6 months.

Prior Authorization (Initial Authorization)

Length of Approval: 6 Months [E]
For diagnosis of Preventive Treatment of Episodic Migraine

Both of the following:

Diagnosis of episodic migraines

AND

Patient has greater than or equal to 4 migraine days per month [26]

AND

Patient is 18 years of age or older [I]

AND

History of failure (after at least a two month trial), contraindication, or intolerance to TWO of the following preventive treatments for migraine from different mechanisms of action [D, E, F, G, 10]:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Nurtec ODT

Nurtec ODT: For use for preventive treatment of migraine, please enter a quality limit override of #16 tablets per 30 days (MDD, 0.54) for 12 months.

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Preventive Treatment of Episodic Migraine

Patient has experienced a positive response to therapy (e.g., a reduction in headache frequency and/or intensity, a reduction in the number of workdays missed due to migraines)

AND

Use of acute migraine medications [e.g., nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen), triptans (e.g., eletriptan, rizatriptan, sumatriptan)] has decreased since the start of CGRP therapy

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Nurtec ODT

Note: For use for preventive treatment of migraine, please enter a quality limit override of #16 tablets per 30 days (MDD, 0.54) for 6 months.

Non Formulary

Length of Approval: 6 Months [E]
For diagnosis of Preventive Treatment of Episodic Migraine

Both of the following:

Submission of medical records (e.g., chart notes) confirming a diagnosis of episodic migraines

AND

Submission of medical records (e.g., chart notes) confirming the patient has greater than or equal to 4 migraine days per month [26]

AND

Patient is 18 years of age or older [I]

AND

Paid claims or submission of medical records (e.g., chart notes) confirming history of failure (after at least a two month trial), contraindication, or intolerance to TWO of the following preventive treatments for migraine from different mechanisms of action [D, E, F, G, 10]:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Qulipta

Prior Authorization (Initial Authorization)

Length of Approval: 6 Months [E]
For diagnosis of Preventive Treatment of Migraine

One of the following:

Both of the following:

Diagnosis of episodic migraines

AND

Patient has greater than or equal to 4 migraine days per month [28]

All of the following:

Diagnosis of chronic migraines

AND

Patient has greater than or equal to 8 migraine days per month [A]

AND

Medication overuse headache has been considered and potentially offending medication(s) have been discontinued [H]

AND

Patient is 18 years of age or older [I]

AND

History of failure (after at least a two month trial), contraindication, or intolerance to TWO of the following preventive treatments for migraine from different mechanisms of action [D, E, F, G, 10]:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Qulipta

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Preventive Treatment of Migraine

Patient has experienced a positive response to therapy (e.g., a reduction in headache frequency and/or intensity, a reduction in the number of workdays missed)

AND

Use of acute migraine medications [e.g., nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen), triptans (e.g., eletriptan, rizatriptan, sumatriptan)] has decreased since the start of CGRP therapy

AND

For Chronic Migraine only: Patient continues to be monitored for medication overuse headache (MOH) [H]

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Qulipta

Non Formulary

Length of Approval: 6 Months [E]
For diagnosis of Preventive Treatment of Migraine

One of the following:

Both of the following:

Submission of medical records (e.g., chart notes) confirming a diagnosis of episodic migraines

AND

Submission of medical records (e.g., chart notes) confirming the patient greater than or equal to 4 migraine days per month [28]

All of the following:

Submission of medical records (e.g., chart notes) confirming a diagnosis of chronic migraines

AND

Submission of medical records (e.g., chart notes) confirming a patient has greater than or equal to 8 migraine days per month [A]

AND

Submission of medical records (e.g., chart notes) confirming a medication overuse headache has been considered and potentially offending medication(s) have been discontinued [H]

AND

Patient is 18 years of age or older [I]

AND

Paid claims or submission of medical records (e.g., chart notes) confirming history of failure (after at least a two month trial), contraindication, or intolerance to TWO of the following preventive treatments to migraine from different mechanisms of action [D, E, F, G, 10]:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Vyepti

Prior Authorization (Initial Authorization)

Length of Approval: 6 Months [E]
For diagnosis of Preventive Treatment of Migraine

One of the following:

Both of the following:

Diagnosis of episodic migraines

AND

Patient has greater than or equal to 4 migraine days per month [A, B, C]

All of the following:

Diagnosis of chronic migraines

AND

Patient has greater than or equal to 8 migraine days per month [A]

AND

Medication overuse headache has been considered and potentially offending medication(s) have been discontinued [H]

AND

Patient is 18 years of age or older [I]

AND

History of failure (after at least a two month trial), contraindication, or intolerance to TWO of the following preventative treatments for migraine from different mechanisms of action [D, E, F, G, 10]:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Trial and failure, contraindication or intolerance to BOTH of the following:

Aimovig
Ajovy

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Vyepti

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Preventive Treatment of Migraine

Patient has experienced a positive response to therapy (e.g., a reduction in headache frequency and/or intensity, a reduction in the number of workdays missed due to migraines)

AND

Use of acute migraine medications [e.g., nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen), triptans (e.g., eletriptan, rizatriptan, sumatriptan)] has decreased since the start of CGRP therapy

AND

For Chronic Migraine only: Patient continues to be monitored for medication overuse headache (MOH) [H]

AND

Trial and failure, contraindication, or intolerance to BOTH of the following:

Aimovig
Ajovy

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Vyepti

Non Formulary

Length of Approval: 6 Months [E]
For diagnosis of Preventive Treatment of Migraine

One of the following:

Both of the following:

Submission of medical records (e.g., chart notes) confirming a diagnosis of episodic migraines

AND

Submission of medical records (e.g., chart notes) the patient has greater than or equal to 4 migraine days per month [A, B, C]

All of the following:

Submission of medical records (e.g., chart notes) confirming a diagnosis of chronic migraines

AND

Submission of medical records (e.g., chart notes) confirming the patient has greater than or equal to 8 migraine days per month [A]

AND

Medication overuse headache has been considered and potentially offending medication(s) have been discontinued [H]

AND

Patient is 18 years of age or older [I]

AND

Paid claims or submission of medical records (e.g., chart notes) confirming history of failure (after at least a two month trial), contraindication, or intolerance to TWO of the following preventative treatments for migraine from different mechanisms of action [D, E, F, G, 10]:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Both of the following:

Submission of medical records (e.g., chart notes) confirming a history of failure after at least a 12 week trial to BOTH of the following (unless there is a contraindication or intolerance):

Aimovig
Ajovy

AND

Submission of medical records (e.g., chart notes) confirming a history of failure after at least an 8 week trial to ONE of the following (unless there is a contraindication or intolerance):

Nurtec ODT
Qulipta

AND

Medication will not be used in combination with another CGRP inhibitor for the PREVENTIVE treatment of migraines

Emgality 100 mg/mL

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Episodic Cluster Headaches

Diagnosis of episodic cluster headache

AND

Patient has experienced at least 2 cluster periods lasting from 7 days to 365 days, separated by pain-free periods lasting at least three months [21]

AND

Patient is 18 years of age or older [I]

AND

Medication will not be used in combination with another injectable CGRP inhibitor

Emgality 100 mg/mL

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Episodic Cluster Headaches

Patient has experienced a positive response to therapy (e.g., a reduction in headache frequency and/or intensity, a reduction in the number of workdays missed)

AND

Medication will not be used in combination with another injectable CGRP inhibitor

Nurtec ODT

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Acute Treatment of Migraine

Diagnosis of migraine with or without aura

AND

Will be used for the acute treatment of migraine

AND

Patient is 18 years of age or older [I]

AND

One of the following: [24]

Trial and failure or intolerance to two triptans (e.g., eletriptan, rizatriptan, sumatriptan)
Contraindication to all triptans

AND

If patient has 4 or more headache days per month, one of the following [D, 24]:

Patient must be currently treated with ONE preventive treatment for migraine from the following:

Elavil [amitriptyline]
Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium]
Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

Patient has a history of failure (after at least a two month trial), contraindication or intolerance to ONE preventative treatment for migraine from the following:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Medication will not be used in combination with another CGRP inhibitor for the ACUTE treatment of migraines

Nurtec ODT

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Acute Treatment of Migraine

Patient has experienced a positive response to therapy (e.g., reduction in pain, photophobia, phonophobia, nausea)

AND

Medication will not be used in combination with another CGRP inhibitor for the ACUTE treatment of migraines

Nurtec ODT

Non Formulary

Length of Approval: 3 Month(s)
For diagnosis of Acute Treatment of Migraine

Submission of medical records (e.g., chart notes) confirming a diagnosis of migraine with or without aura

AND

Submission of medical records (e.g., chart notes) confirming drug will be used for the acute treatment of migraine

AND

Patient is 18 years of age or older [I]

AND

Paid claims or submission of medical records (e.g., chart notes) confirming one of the following: [24]

Trial and failure or intolerance to two triptans (e.g., eletriptan, rizatriptan, sumatriptan)
Contraindication to all triptans

AND

Paid claims or submission of medical records (e.g., chart notes) one of the following: [D, 24]

Patient must be currently treated with ONE preventive treatment for migraine from the following:

Elavil [amitriptyline]
Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium]
Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

Patient has a history of failure (after at least a two month trial), contraindication, or intolerance to THREE preventative treatments for migraine from the following different mechanisms of action:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Medication will not be used in combination with another CGRP inhibitor for the ACUTE treatment of migraines

Ubrelvy

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Acute Treatment of Migraine

Diagnosis of migraine with or without aura

AND

Will be used for the acute treatment of migraine

AND

Patient is 18 years of age or older [I]

AND

One of the following: [24]

Trial and failure or intolerance to two triptans (e.g., eletriptan, rizatriptan, sumatriptan)
Contraindication to all triptans

AND

If patient has 4 or more headache days per month, one of the following [D, 24]:

Patient must be currently treated with ONE preventive treatment for migraine from the following:

Elavil [amitriptyline]
Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium]
Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

Patient has a history of failure (after at least a two month trial), contraindication or intolerance to ONE preventative treatment for migraine from the following:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Medication will not be used in combination with another CGRP inhibitor for the ACUTE treatment of migraines

Ubrelvy

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Acute Treatment of Migraine

Patient has experienced a positive response to therapy (e.g., reduction in pain, photophobia, phonophobia, nausea)

AND

Will not be used for preventive treatment of migraine

AND

Medication will not be used in combination with another CGRP inhibitor for the acute treatment of migraines

Ubrelvy

Non Formulary

Length of Approval: 3 Month(s)
For diagnosis of Acute Treatment of Migraine

Submission of medical records (e.g., chart notes) confirming a diagnosis of migraine with or without aura

AND

Submission of medical records (e.g., chart notes) confirming drug will be used for the ACUTE treatment of migraine

AND

Patient is 18 years of age or older [I]

AND

Paid claims or submission of medical records (e.g., chart notes) confirming one of the following: [24]

Trial and failure or intolerance to two triptans (e.g., eletriptan, rizatriptan, sumatriptan)
Contraindication to all triptans

AND

Paid claims or submission of medical records (e.g., chart notes) confirming that if patient has 4 or more headache days per month, one of the following: [D, 24]

Patient must be currently treated with ONE preventive treatment for migraine from the following:

Elavil [amitriptyline]
Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium]
Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

Patient has a history of failure (after at least a two month trial), contraindication, or intolerance to THREE preventative treatments for migraine from the following:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Medication will not be used in combination with another CGRP inhibitor for the ACUTE treatment of migraines

Zavzpret

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Acute Treatment of Migraine

Diagnosis of migraine with or without aura

AND

Will be used for the acute treatment of migraine

AND

Patient is 18 years of age or older [I]

AND

One of the following: [24]

Trial and failure or intolerance to two triptans (e.g., eletriptan, rizatriptan, sumatriptan)
Contraindication to all triptans

AND

If patient has 4 or more headache days per month, one of the following: [D, 24]

Patient must be currently treated with ONE preventive treatment for migraine from the following:

Elavil [amitriptyline]
Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium]
Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

Patient has a history of failure (after at least a two month trial), contraindication, or intolerance to ONE preventative treatment for migraine from the following:

Elavil [amitriptyline] or Effexor [venlafaxine]
Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
Atenolol, propranolol, nadolol, timolol, or metoprolol
Candesartan
Lisinopril

AND

Medication will not be used in combination with another CGRP inhibitor for the ACUTE treatment of migraines

Zavzpret

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Acute Treatment of Migraine

Patient has experienced a positive response to therapy (e.g., reduction in pain, photophobia, phonophobia, nausea)

AND

Will not be used for preventive treatment of migraine

AND

Medication will not be used in combination with another CGRP inhibitor for the ACUTE treatment of migraines

Guideline ID
GL-150678
Formulary
Premium
Effective date
Sep 1, 2024
P&T approval date
May 17, 2018

P & T Revisions

2024-07-31, 2024-07-08, 2024-04-30, 2024-04-24, 2024-04-24, 2024-04-17, 2024-03-07, 2024-02-22, 2024-02-01, 2023-10-24, 2023-08-22, 2023-05-26, 2023-05-03, 2023-02-15, 2022-08-19, 2022-07-12, 2022-04-06, 2022-03-08, 2022-03-08, 2022-01-06, 2021-11-16, 2021-09-07, 2021-07-07, 2021-05-20, 2021-01-06, 2020-08-06, 2020-05-14, 2020-03-18, 2020-01-14, 2019-11-22, 2019-10-29, 2019-07-01

References

Aimovig Prescribing Information. Amgen Inc. Thousand Oaks, CA. May 2023.
Amgen press release. When Others Fail, New Migraine Treatment May Work. April 17, 2018.
ClinicalTrials.gov. A Study Evaluating the Effectiveness of AMG 334 Injection in Preventing Migraines in Adults Having Failed Other Therapies (LIBERTY). NCT03096834. Website. https://clinicaltrials.gov/ct2/show/NCT03096834?term=NCT03096834&rank=1.
ClinicalTrials.gov. Efficacy and Safety of 2 Dose Regimens of TEV-48125 Versus Placebo for the Preventive Treatment of Episodic Migraine. NCT02629861. Website. https://clinicaltrials.gov/ct2/show/NCT02629861?term=NCT02629861&rank=1.
ClinicalTrials.gov. Evaluation of LY2951742 in the Prevention of Chronic Migraine (REGAIN). NCT02614261. Website. https://clinicaltrials.gov/ct2/show/NCT02614261?term=NCT02614261&rank=1.
ClinicalTrials.gov. Evaluation of LY2951742 in the Prevention of Episodic Migraine- the EVOLVE-1 Study (EVOLVE-1). NCT02614183. Website. https://clinicaltrials.gov/ct2/show/NCT02614183?term=NCT02614183&rank=1.
ClinicalTrials.gov. Evaluation of LY2951742 in the Prevention of Episodic Migraine- the EVOLVE-2 Study (EVOLVE-2). NCT02614196. Website. https://clinicaltrials.gov/ct2/show/NCT02614196?term=NCT02614196&rank=1.
ClinicalTrials.gov. Study to Evaluate the Efficacy and Safety of AMG 334 Compared to Placebo in Migraine Prevention (ARISE). NCT02483585. Website. https://clinicaltrials.gov/ct2/show/NCT02483585?term=NCT02483585&rank=1.
Goadsby PJ, Reuter U, Hallström Y, et al. A Controlled Trial of Erenumab for Episodic Migraine (STRIVE). N Engl J Med. 2017 Nov 30;377(22):2123-2132.
Institute for Clinical and Economic Review Draft Evidence Report. Calcitonin Gene-Related Peptide (CGRP) Inhibitors as Preventive Treatments for Patients with Episodic or Chronic Migraine: Effectiveness and Value. April 2018. Available here: https://icer-review.org/wp-content/uploads/2017/11/ICER_Migraine_Draft_Report_041118.pdf. Accessed February 1, 2023.
International Headache Society (IHS); Headache Classification Committee. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33: 629-808.
Lipton RB, Silberstein SD. Episodic and chronic migraine headache: breaking down barriers to optimal treatment and prevention. Headache. 2015 Mar;55 Suppl 2:103-22.
National Institute for Health and Care Excellence. Management of migraine (with or without aura). April 17th, 2018. Available at: https://pathways.nice.org.uk/pathways/headaches/management-of-migraine-with-or-without-aura#path=view%3A/pathways/headaches/management-of-migraine-with-or-without-aura.xml&content=view-node%3Anodes-prophylactic-treatment. Accessed December 7, 2021.
Per Clinical Consultation with a Neurologist. January 24, 2018.
Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012 Apr 24;78(17):1337-45.
Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2016 May 10;86(19):1818-26.
Vyepti Prescribing Information. Lundbeck Seattle BioPharmaceuticals, Inc. Bothell, WA. October 2022.
Nurtec ODT Prescribing Information. Biohaven Pharmaceuticals, Inc. New Haven, CT. April 2023.
Ajovy Prescribing Information. Teva Pharmaceuticals USA, Inc. North Wales, PA. October 2022.
Emgality Prescribing Information. Eli Lilly and Company. Indianapolis, IN. March 2021.
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Ubrelvy Prescribing Information. Allergan USA, Inc. Madison, NJ. March 2021.
Dodick DW, Lipton RB, Ailani J, et al. Ubrogepant for the Treatment of Migraine. N Engl J Med. 2019 Dec 5;381(23):2230-2241.
AHS Consensus Statement. Update on integrating new migraine treatments into clinical practice. Headache. 2021 Jul;61(7):1021-1039.
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Croop R, Lipton RB, Kudrow D, et al.Oral rimegepant for preventive treatment of migraine: a phase 2/3, randomised, double-blind, placebo-controlled trial. Lancet. 2021 Jan 2;397(10268):51-60.
Qulipta Prescribing Information. Forest Laboratories Ireland Ltd. Dublin, Ireland. April 2023.
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Zavzpret Prescribing Information. Pfizer Inc. New York, NY. March 2023.
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Revision History

2024-07-31: Formatting correction. No clinical changes.
2024-07-08: 1) Updated T/F language to specify options available & categorize by mechanism of action, instead of class. 2) Revised T/F requirement of preventive treatment in patients with over 4 headache days/month for the acute tx of migraine. 3) Updated NF criteria for preventive tx for Emgality & Vyepti to require a T/F of two injectable & one oral CGRP inhibitor.
2024-04-30: Updated criteria language with clearer clinical intent.
2024-04-24: updated effective date.
2024-04-24: Background updates - corrected GPIs and spelling errors.
2024-04-17: Background updates. Simplified definition of episodic and chronic migraines and streamlined criteria for all drugs within the guideline. Formatting changes to trial/ failure options for preventive treatment of migraine criteria, to make clinical intent more clear. Added lisinopril as a t/f option.
2024-03-07: 2024 annual review. No changes to clinical content.
2024-02-22: Updated criteria language to standard non-formulary for Vyepti.
2024-02-01: Commercial formulary strategy update. Modified PA criteria to require a trial and failure, contraindication or intolerance to both Aimovig and Ajovy.
2023-10-24: Update guideline
2023-08-22: New UM PA Criteria for Zavzpret
2023-05-26: Updated criteria for Qulipta with expanded indication of preventative treatment of migraine. Updated background and references.
2023-05-03: Per PA team feedback, updated T/F criteria language for Nurtec ODT, Qulipta, and Ubrelvy for clarity (no changes to clinical intent).
2023-02-15: Annual review - per Appeals team feedback, reformatted T/F criteria for Nurtec ODT, Qulipta, and Ubrelvy for clarity (no changes to clinical intent). Also removed criterion "will not be used for preventative tx of migraine" from Ubrelvy initial criteria per Appeals team request. Updated references.
2022-08-19: Added T/F requirement through aimovig and ajovy for Emgality 120mg/ml reauth criteria.
2022-07-12: Added NF criteria for Nurtec ODT and Ubrelvy. Formulary strategy for Qulipta to remove trial requirements through Aimovig, Ajovy, and Nurtec.
2022-04-06: Updated criteria and operational note.
2022-03-08: This guideline version adds EHB back in to mirror ORx's criteria and formulary strategy.
2022-03-08: Updated formulary strategy for prophylactic migraine agents. Removed non-formulary criteria for Ajovy and added non-formulary criteria for Emgality 120 mg/mL.
2022-01-06: Annual Review: Updated criteria and background. Includes addition of operational note for Emgality.
2021-11-16: Added Qulipta to the guideline and updated used in combination criterion for preventive treatment indication.
2021-09-07: Updated initial and reauthorization criteria for acute treatment of migraine for Nurtec. Added non-formulary criteria for Ajovy. Updated guideline name.
2021-07-07: Added criteria for new indication for Nurtec.
2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
2021-01-06: Updated prescriber requirement. Annual review: Spelled out abbreviation and added drug examples to migraine reauthorization criteria.
2020-08-06: Updated initial and reauthorization criteria (all drugs and indications).
2020-05-14: Vyepti, Nurtec ODT, and Ajovy autoinjector formulation added to guideline. Updated criteria associated with Ubrelvy and Nurtec ODT. Assigned strength to specific Emgality indications. Additional criterion added to all existing drugs for initial and reauthorization.
2020-03-18: Added criteria for new drug, Ubrelvy.
2020-01-14: Annual Review: Added GPI for Emgality 100 mg/mL and background updates.
2019-11-22: Removed tech note.
2019-10-29: Removal of criterion and background updates.
2019-07-01: Added criteria for new indication of episodic cluster headache for Emgality requiring the following for initial authorization (approvable for 3 months): diagnosis of episodic cluster headache; patient has experienced at least 2 cluster periods lasting from 7 days to 365 days, separated by pain-free periods lasting at least three months; patient is 18 years of age or older; prescribed by or in consultation with one of the following specialists: neurologist, pain specialist; and medication will not be used in combination with another CGRP inhibitor. Reauthorization (approvable for 12 months) requires the following: patient has experienced a positive response to therapy, demonstrated by a reduction in headache frequency and/or intensity and prescribed by or in consultation with one of the following specialists: neurologist, pain specialist. EAH 7/1/19

CGRP Inhibitors - PA, NF

Indications for Prior Authorization

Aimovig (erenumab-aooe), Ajovy (fremanezumab-vfrm), Vyepti (eptinezumab-jjmr); Qulipta (atogepant)

Emgality (galcanezumab-gnlm)

Nurtec ODT (rimegepant)

Ubrelvy (ubrogepant), Zavzpret (zavegepant)

Criteria

Aimovig or Ajovy

Aimovig or Ajovy

Emgality 120 mg/mL

Emgality 120 mg/mL

Emgality 120 mg/mL

Nurtec ODT

Nurtec ODT

Nurtec ODT

Qulipta

Qulipta

Qulipta

Vyepti

Vyepti

Vyepti

Emgality 100 mg/mL

Emgality 100 mg/mL

Nurtec ODT

Nurtec ODT

Nurtec ODT

Ubrelvy

Ubrelvy

Ubrelvy

Zavzpret

Zavzpret

P & T Revisions

References

Revision History

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