Calcitonin Gene-Related Peptide (CGRP) agents — Blue Cross Blue Shield of Montana

Initial criteria

• One of the following:
• • The patient has another FDA labeled indication for the requested agent and route of administration OR
• • The patient has another indication supported in compendia for the requested agent and route of administration OR
• • The prescriber has submitted TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use as generally safe and effective (case studies not acceptable)

Reauthorization criteria

• ALL of the following:
• 1. The patient has been approved for the requested agent previously through the plan’s Prior Authorization process AND
• 2. ONE of the following:
• A. BOTH of the following:
• 1. ONE of the following:
• A. The requested agent is used for migraine prophylaxis AND ALL of the following:
• • The patient has had clinical benefit with the requested agent AND
• • The patient will NOT use the requested agent in combination with another prophylactic use CGRP AND
• • ONE of the following:
• A. BOTH of the following:
• • The patient has a diagnosis of chronic migraine (≥15 headache days per month for ≥3 months prior to prevention therapy) AND
• • The requested agent/strength are FDA labeled for chronic migraine OR
• B. BOTH of the following:
• • The patient has a diagnosis of episodic migraine (4–14 monthly migraine days prior to prevention therapy) AND
• • The requested agent/strength are FDA labeled for episodic migraine OR
• B. The requested agent is used for episodic cluster headache AND BOTH of the following:
• • The patient has had clinical benefit with the requested agent AND
• • The requested agent/strength are FDA labeled for episodic cluster headache OR
• C. The requested agent is used for acute migraine AND ALL of the following:
• • The patient has had clinical benefit with the requested agent AND
• • The patient will NOT use the requested agent in combination with another acute migraine therapy (5HT-1F, acute-use CGRP, or ergotamine) for this indication AND
• • The requested agent/strength are FDA labeled for acute migraine treatment AND
• 2. Medication overuse headache has been ruled out OR
• B. The patient has a diagnosis other than migraine prophylaxis, episodic cluster headache treatment, or acute migraine treatment AND has had clinical benefit with the requested agent.
• 3. The patient does not have any FDA labeled contraindications to the requested agent.

Approval duration

12 months