Prior Authorization Criteria for Approval

Initial Evaluation

Emgality will be approved when BOTH of the following are met:

1. ONE of the following:
   1. The patient has a diagnosis of migraine AND ALL of the following:
      1. The requested medication is being used for migraine prophylaxis
         AND
      2. The patient has 4 or more migraine headache days per month
         AND
      3. The patient will NOT be using the requested medication in combination with another calcitonin gene-related peptide (CGRP) medication for migraine prophylaxis
         OR
   2. The patient has a diagnosis of episodic cluster headache AND BOTH of the following:
      1. The patient has had at least 5 cluster headache attacks
         AND
      2. The patient has had at least two cluster periods lasting 7 days to one year and separated by pain-free remission periods of 3 months or more
         AND
2. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
   2. ALL of the following:
      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months

Renewal Evaluation

Emgality will be approved when ALL of the following are met:

1. The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria
   AND
2. ONE of the following:
   1. ALL of the following:
      1. The patient has a diagnosis of migraine
         AND
      2. The requested medication is being used for migraine prophylaxis
         AND
      3. The patient will NOT be using the requested medication in combination with another calcitonin gene-related peptide (CGRP) medication for migraine prophylaxis
         OR
   2. The patient has a diagnosis of episodic cluster headache
      AND
3. The patient has had clinical benefit with the requested medication
   AND
4. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
   2. ALL of the following:
      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months