Fremanezumab-vfrm (Ajovy®)

SELF ADMINISTRATION

Indications for Prior Authorization: 
  • Indicated for the preventative treatment of migraine in adults
Patients must meet the following crtieria for the indication(s) above:
  • Patient is 18 years of age or older, AND
  • Patient has 4 or more migraine headache days per month (prior to initiating a migraine-preventative medication) as supported by chart note documentation, AND
  • Patient has tried and failed at least 2 standard prophylactic pharmacologic therapies, each from a different pharmacologic class (e.g. angiotensin receptor blocker, angiotensin converting enzyme inhibitor, anticonvulsant, ß-blocker, calcium channel blocker, tricyclic antidepressant, other antidepressant), and meets one of the following:
    • Patient has had inadequate efficacy to both of those standard prophylactic pharmacologic therapies, according to the prescribing physician, OR
    • Patient has experienced adverse event(s) severe enough to warrant discontinuation of both of those standard prophylactic pharmacologic therapies, according to the prescribing physician, OR
    • Patient has had inadequate efficacy to one standard prophylactic pharmacologic therapy and has experienced adverse event(s) severe enough to warrant discontinuation to another standard prophylactic pharmacologic therapy, according to the prescribing physician, AND
  • For patients previously on Botox®: patient has not received a Botox® injection in the past 8 weeks, AND
  • Patient will not be initiating Botox® injection therapy, AND
  • Patient will not use Ajovy® in combination with another CGRP receptor antagonist (e.g. Aimovig® or Emgality®), AND
  • Patient has tried and failed Aimovig® or Emgality®
The following conditions do not meet the criteria for use as established by WHA P&T committee: 
  • Acute treatment of migraine, cluster headache, hemiplegic migraine
  • Not approvable for concomitant use with Botox®
Dosing:
  • Recommended dose: 225mg subcutaneously monthly OR 675mg subcutaneously every 3 months 
Approval:
  • Initial: 3 months
  • Renewal: 1 year if chart note documentation denotes a positive clinical response documenting a decrease in the number and frequency of migraine headaches

Last review date: July 23, 2019