Ajovy (fremanezumab) — United Healthcare

Migraine prevention

Preferred products

Diagnosis of migraine consistent with The International Classification of Headache Disorders, 3rd edition
One of the following: (a) 4 to 7 migraine days per month and at least one of: (1) Less than 15 headache days per month OR (2) Provider attests this is the member’s predominant headache diagnosis (i.e., primary driver of headaches is not a different, non-migrainous condition) OR (b) ≥ 8 migraine days per month
Failure (after a trial of at least 2 months; 30 days in CT, KY, MS) OR contraindication OR intolerance to two of the following prophylactic therapies (document name and date tried): beta-blocker (atenolol, metoprolol, nadolol, propranolol, or timolol); candesartan (Atacand); divalproex sodium (Depakote/Depakote ER); onabotulinumtoxinA (Botox); SNRI [duloxetine (Cymbalta), venlafaxine (Effexor/Effexor XR)]; topiramate (Topamax); TCA [amitriptyline (Elavil), nortriptyline (Pamelor)]
Failure (after a trial of at least 3 months; 30 days in CT, KY, MS) OR contraindication OR intolerance to two of the following: Aimovig, Emgality (120 mg strength), Nurtec ODT, or Qulipta
Medication will not be used in combination with another CGRP antagonist or inhibitor for migraine prevention (e.g., Aimovig, Emgality, Nurtec ODT, Qulipta, Vyepti)

Patient has experienced a positive response to therapy, demonstrated by a reduction in headache frequency and/or intensity
Medication will not be used in combination with another CGRP antagonist or inhibitor used for preventive treatment of migraines (e.g., Nurtec ODT, Qulipta, Vyepti)

12 months