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

Initial criteria

• Quantity limit approval granted when ONE of the following is met:
• 1. The requested quantity (dose) does NOT exceed the program quantity limit OR
• 2. The requested quantity exceeds the program limit AND ONE of the following:
• A. BOTH of the following:
• • The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
• • There is support for therapy with a higher dose for the requested indication OR
• B. BOTH of the following:
• • The requested quantity does NOT exceed the maximum FDA labeled dose for the requested indication AND
• • There is support for why this dose cannot be achieved with a lower quantity of a higher strength that remains within program limits OR
• C. ALL of the following:
• • The requested quantity exceeds the maximum FDA labeled dose for the requested indication AND
• • If the requested agent is used for acute migraine, then ONE of the following:
• A. The patient is currently treated with a migraine prophylactic medication (anticonvulsants [divalproex, valproate, topiramate]; beta blockers [atenolol, metoprolol, nadolol, propranolol, timolol]; tricyclic antidepressants [amitriptyline, nortriptyline]; SNRIs [venlafaxine, duloxetine]; candesartan; prophylactic CGRP [Aimovig, AJOVY, Emgality, Nurtec ODT, QULIPTA, Vyepti]; or onabotulinumtoxin A [BOTOX]) OR
• B. The patient has intolerance or hypersensitivity to all migraine prophylactic medications listed above OR
• C. The patient has an FDA labeled contraindication to ALL migraine prophylactic medications listed above OR
• D. There is support that the patient’s migraine is manageable with acute therapy alone AND
• • There is support for therapy with a higher dose for the requested indication.

Approval duration

BCBSIL: 12 months; other plans: initial 6 months for migraine prophylaxis or 12 months for other indications; renewal 12 months