Ajovy (fremanezumab-vfrm) — Highmark

migraine (episodic or chronic)

Initial criteria

age ≥ 18 years
diagnosis of migraine (ICD-10: G43) classified as either episodic migraine (4–14 headache days per month) OR chronic migraine (≥15 headache days per month of which ≥8 are migraine days)
prescriber attests to: (a) baseline average monthly migraine days, (b) headaches not due to medication rebound/overutilization or lifestyle factors, AND (c) therapeutic failure or intolerance to one (1) agent from two (2) different prophylactic migraine medication classes OR all are contraindicated (alpha-agonists; ACE inhibitors or ARBs; anti-epileptics; beta-blockers; calcium channel blockers; SNRIs; tricyclic antidepressants)
if two chemically distinct CGRP inhibitors will be used concurrently for prevention and acute use, prescriber attests that benefits outweigh the risks

reduction in migraine days per month by at least 50% from baseline OR episodic migraine: ≥4-day reduction from baseline OR chronic migraine: ≥5-day reduction from baseline
subsequent reauthorizations require sustained improvement