Emgality — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years
• Patient has between one headache every other day and eight headaches per day
• Patient has tried at least one standard prophylactic pharmacologic therapy for cluster headache
• Patient has had inadequate efficacy OR experienced adverse events severe enough to warrant discontinuation of the prophylactic therapy
• Site of care medical necessity is met

Reauthorization criteria

• If the patient is currently taking a CGRP antagonist, the patient has had a clinical benefit from the medication as determined by the prescriber
• Site of care medical necessity is met

Approval duration

3 months initial; 6 months continuation