Emgality — Highmark

Initial criteria

• age ≥ 18 years
• diagnosis of episodic cluster headache (ICD-10: G44.01) characterized by severe or very severe unilateral orbital, supraorbital, and/or temporal pain, lasting 15 to 180 minutes when left untreated
• member is experiencing attack frequency of at least one attack every other day during a cluster period

Reauthorization criteria

• The prescriber attests that the member has experienced a reduction in the number of mean weekly cluster headaches from baseline.
• Subsequent reauthorizations are subject to sustained improvements noted above.

Approval duration

initial 6 months (12 months for Delaware), reauth 12 months