CGRP Antagonists

Preferred Drug - Emgality™ (galcanezumab-gnlm) [Eli Lilly and Company]

Nonpreferred Drugs - Aimovig™ (erenumab-aooe) [Amgen Inc.]
Ajovy™ (fremanezumab-vfrm) [Teva Pharmaceuticals USA, Inc.]

January 2019

Therapeutic area - Antimigraine Preparations, CGRP Antagonists

Initial approval criteria for preferred drug

Preferred drug is prescribed by, or in consultation with a specialist (including neurologist or pain specialist) AND
Patient has a diagnosis of migraine with or without aura based on International Classification of Headache Disorders (ICHD-III) diagnostic criteria AND
Medication overuse headache has been ruled out by trial and failure of titrating off acute migraine treatments in the past AND
Patient has ≥ 4 migraine days per month for at least 3 months AND
Patient has tried and failed a ≥ 1 month trial of any 2 of the following oral medications:
- Antidepressants (e.g., amitriptyline, venlafaxine)
- Beta blockers (e.g., propranolol, metoprolol, timolol, atenolol)
- Anti-epileptics (e.g., valproate, topiramate)
- Angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (e.g., lisinopril, candesartan)
Initial approval is for 3 months

Patient must meet all initial approval criteria for preferred drug AND
Patient has tried and failed a 3-month trial of the preferred drug, unless contraindicated
Initial approval is for 3 months

Patient demonstrated significant decrease in the number, frequency, and/or intensity of headaches AND
Patient has an overall improvement in function with therapy AND
Absence of unacceptable toxicity (e.g., intolerable injection site pain)
Renewal approval is for 12 months

Ajovy: 1 prefilled syringe per 30 days
Aimovig: 2 syringes or autoinjectors per 30 days
Emgality: 2 prefilled pens or syringes for the first 30 days; 1 prefilled pen or syringe per 30 days thereafter

MHCP Provider Call Center 651-431-2700 or 800-366-5411