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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: Aimovig (erenumab)
Revision Date: Document: BI585:00
CPT Code(s): None
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)    Aimovig (erenumab) requires prior authorization.

2)    Aimovig is used for the prevention of migraine headaches.

3)    Aimovig is covered under the pharmacy benefit.


Medical Statement

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

 

Aimovig (erenumab) is 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)    Aimovig is 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 (3 months) 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)

6)    Patient has completed an adequate trial (3 months) of at least one triptan (e.g. sumatriptan, naratriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan).

7)    Member will not be using Aimovig with Botox for prevention of migraines.

 

Re-authorization criteria>

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.


Limits

Aimovig is limited to a maximum quantity of 6 per 90 days.


Reference

1)    Aimovig Prescribing Information.  Amgen. May 2018.

2)    Clinical Pharmacology. Accessed online 09/14/2018.


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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