Limited coverage drugs – fremanezumab

Last updated on August 26, 2024

 

Generic name: fremanezumab

Strength & form

225 mg in 1.5 mL (150 mg/mL) solution for subcutaneous injection

Special Authority criteria

Approval period

Initial

  • The patient has a confirmed diagnosis of episodic or chronic migraine defined as:
    • Episodic migraine: Migraine headaches on at least 4 days per month and less than 15 headache days per month for more than 3 months
    • Chronic migraine: Migraine headaches on at least 8 days per month and headaches for at least 15 days per month for more than 3 months

AND

  • The patient has experienced an inadequate response for a minimum three months trial at optimal dosing or intolerance to at least two oral prophylactic migraine medications from two different therapeutic classes. Required details of trial include: names, doses and durations of the previously tried prophylactic migraine medications1. In cases of intolerance, also include details regarding the nature and severity of the intolerance(s) experienced

AND

  • The baseline number of headache and migraine days per month2 at the time of initial request is provided

6 months

First renewal

The patient has had a minimum reduction of at least 50% in the average number of migraine days per month2 compared to baseline

6 months

Second and subsequent renewals

The patient has maintained a minimum reduction of at least 50% in the average number of migraine days per month2 compared to baseline

1 year

Practitioner exemptions

  • No practitioner exemptions

Special notes

Therapeutic class

Anti-seizure medications:

  • Divalproex sodium / valproic acid
  • Topiramate
  • Gabapentin

Serotonin and norepinephrine reuptake inhibitors:

  • Duloxetine
  • Venlafaxine

Beta-blockers:

  • Atenolol
  • Metoprolol
  • Nadolol
  • Propranolol
  • Timolol

Tricyclic antidepressants:

  • Nortriptyline
  • Amitriptyline

Calcium channel blockers:

  • Flunarizine
  • Verapamil

Renin-angiotensin-aldosterone system inhibitors:

  • Candesartan
  • Lisinopril

Miscellaneous:

  • Pizotifen
  • 2Special Authority will not accept changes to the baseline migraine days per month during renewal requests. Number of migraine days should be calculated using data from a migraine journal or application kept by the patient over the 3-month period immediately preceding this request
  • PharmaCare will not provide combination coverage for CGRP antagonists used for migraine prevention
  • The patient should be under the care of a practitioner who has appropriate experience in the management of patients with migraine headaches

Special Authority request form(s)