Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 11/01/2018 Title: Calcitonin Gene Related Peptide (CGRP) Inhibitors
Revision Date: 06/01/2020 Document: BI585:00
CPT Code(s): J3031
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    All covered calcitonin gene related peptide (CGRP) inhibitors require prior authorization. These include Aimovig (erenumab), Emgality (galcanezumab), Vyepti (eptinezumab), Ubrelvy (ubrogepant), and Nurtec (rimegepant).

2)    Aimovig (erenumab), Emgality (galcanezumab), and Vyepti (eptinezumab) are used for the prevention of migraine headaches.

3)    Ubrelvy (ubrogepant) and Nurtec (rimegepant) are used for the acute treatment of migraine headaches.

4)    Aimovig, Emgality, Ubrelvy, and Nurtec are covered under the pharmacy benefit.

5)    Vyepti is covered under the medical benefit.

6)    Ajovy (fremanezumab) is not covered.


Medical Statement

For Migraine Prevention (Aimovig, Emgality, Vyepti)

If approved, initial authorization will be for six (6) months.

 

Aimovig (erenumab), Emgality (galcanezumab), and Vyepti (eptinezumab) are considered medically necessary in members meeting the following conditions:

1)    Patient is 18 years of age or older; AND

2)    Diagnosis of migraine headaches; AND

3)    Being used for the prevention of migraines; AND

4)    Documentation of at least eight (8) migraines per month; AND

5)    Patient has had inadequate response to an adequate trial (60 days) of a product from at least two of the drug classes below:

a.    Beta Blockers (e.g. atenolol, propranolol)

b.    Anticonvulsants (e.g. topiramate, gabapentin, divalproex)

c.    Antidepressants (e.g. amitriptyline, venlafaxine)

d.    Calcium Channel Blockers (e.g. verapamil); AND

6)    Member will not be using Aimovig, Emgality, or Vyepti with Botox for prevention of migraines.

7)    Members will be using only one CGRP inhibitor for prevention of migraines.

 

Re-authorization criteria (12 months duration):

1)    Documented decrease of > 50% in migraine frequency from baseline; AND

2)    Decrease in use of acute migraine medications; AND

3)    No dual therapy with Botox.

 

Episodic Cluster Headaches (Emgality only)

Emgality is considered medically necessary for patients 18 years of age or older meeting the following criteria:

1)    Diagnosis of episodic cluster headaches as evidenced by both of the following:

a.    > 1 cluster headache attack every other day and < 8 cluster headache attacks per day with a total of > 5 previous attacks;

b.    > 2 cluster periods lasting < 1 year each and separated by > 3 months;

AND

2)    Failure of verapamil at a dose of 360mg/day, unless contraindicated or clinically significant adverse effects are experienced AND

3)    Emgality is not prescribed concurrently with other injectable CGRP inhibitors (e.g. Aimovig or Ajovy) AND

4)    Dose does not exceed 300mg once monthly

For Acute Treatment of Migraines (Ubrelvy and Nurtec)

If approved, initial authorization will be for six (6) months.

Ubrelvy and Nurtec, oral CGRP inhibitors, are considered medically necessary for members 18 years of age and older who meet the following criteria:

 

1)    Diagnosis of migraine headaches with or without aura;

2)    The prescriber has ruled out medication overuse as a possible cause of migraine;

3)    Patient has an adequate trial (minimum 2 months) of at least two (2) generic triptans with inadequate response or demonstrated intolerance OR

4)    Patient has one of the following cardiovascular or non-coronary vascular contraindications to use of triptans:

a.    Ischemic coronary artery disease (CAD) including angina pectoris, history of myocardial infarction, documented silent ischemia, coronary artery vasospasm (including Prinzmetal’s angina) OR

b.    History of stroke or transient ischemic attack (TIA) OR

c.    Peripheral vascular disease OR

d.    Ischemic bowel disease OR

e.    Uncontrolled hypertension


Limits

1)    Aimovig is limited to a maximum quantity of 420 mg per 90 days.

2)    Emgality is limited to a maximum quantity of 480 mg per 90 days for migraines or 900 mg per 90 days for cluster headaches.

3)    Vyepti is limited to one (1) 300mg dose every 3 months.

4)    Ubrelvy is limited to ten (10) tablets every 30 days.

5)    Nurtec is limited to sixteen (16) tablets every 30 days.


Reference

1)    Aimovig Prescribing Information.  Amgen. May 2018.

2)    Emgality Prescribing Information. Eli Lilly. September 2018.

3)    Ubrelvy Prescribing Information. Madison, NJ; Allergan USA, Inc. December 2019.

4)    Nurtec Prescribing Information. New Haven, CT; Biohaven Pharmaceuticals, Inc. February 2020.

5)    Clinical Pharmacology. Accessed online 04-30-20.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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