Medicare AdvantagePrior AuthMedium impact
Calcitonin gene-related peptide (CGRP) inhibitors (Revised)
Humana·Neurology, Pain Management, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jul 22, 2026
Summary
This is a revised Medicare Advantage prior authorization policy for CGRP inhibitors (Aimovig, Ajovy, Emgality) effective January 1, 2025, with updates as of July 22, 2026. The policy establishes specific authorization criteria: for Emgality episodic cluster headache treatment, members must have diagnosed episodic cluster headaches and failed verapamil trial; for migraine prevention with Aimovig or Ajovy, members must have prior treatment with both Emgality AND Qulipta. All CGRP inhibitor requests require prior authorization before dispensing.
Action Required
By January 1, 2025: Billing team must implement prior authorization requirements for all CGRP inhibitor claims (Aimovig, Ajovy, Emgality) for Medicare Advantage members. Providers must submit prior auth requests documenting: (1) For Emgality cluster headache: diagnosis of episodic cluster headaches with at least two cluster periods lasting 7 days to 1 year separated by ≥1 month remission, AND evidence of verapamil trial failure; (2) For Aimovig/Ajovy migraine prevention: documentation of prior treatment with BOTH Emgality AND Qulipta. Update authorization templates in billing system, provider ordering workflows, and prior auth submission portals to capture these requirements. Notify providers of new criteria immediately. Claims submitted without required prior authorization or missing documentation will be denied. Pharmacy team must flag requests that do not meet criteria before dispensing.