Coverage Policies

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

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

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: 04/01/2019 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 and Emgality are used for the prevention of migraine headaches.

2)    Aimovig (erenumab) and Emgality (galcanezumab) require prior authorization.

3)    Aimovig and Emgality are covered under the pharmacy benefit.

4)    Ajovy (fremanezumab) is not covered.


Medical Statement

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

 

Aimovig (erenumab) or Emgality (galcanezumab) 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)    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 or Emgality 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

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

2)    Emgality is limited to a maximum quantity of 4 per 90 days.


Reference

1)    Aimovig Prescribing Information.  Amgen. May 2018.

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

3)    Clinical Pharmacology. Accessed online 03-18-2019.


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.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.