By Counterforce Health Team in Emgality (galcanezumab-gnlm) —

How to Get Emgality Covered by Blue Cross Blue Shield of Michigan: Prior Authorization Forms, Appeal Process, and Timeline

Quick Answer: Getting Emgality Approved in Michigan

Blue Cross Blue Shield of Michigan (BCBSM) requires prior authorization for Emgality (galcanezumab) with specific medical criteria. You'll need documented failure of at least two traditional migraine preventives (typically topiramate and propranolol) plus a detailed migraine diary showing ≥15 headache days monthly. Submit requests via CoverMyMeds, fax to 1-866-601-4425, or call 1-800-437-3803. If denied, Michigan's DIFS external review process gives you 127 days to appeal with binding outcomes within 60 days (72 hours for urgent cases).

First step today: Contact your prescriber to document your migraine frequency and prior treatment failures, then initiate the PA request through your provider.

Table of Contents

What This Guide Covers

This guide helps Michigan patients and their healthcare providers navigate Blue Cross Blue Shield of Michigan's prior authorization process for Emgality (galcanezumab-gnlm), a CGRP inhibitor used for migraine prevention. We'll walk through BCBSM's specific requirements, submission processes, and what to do if your initial request is denied.

Who this helps:

  • Patients with chronic migraines (≥15 headache days/month)
  • Those who've failed traditional preventive medications
  • Providers submitting PA requests for CGRP inhibitors
  • Anyone facing an Emgality denial from BCBSM

Based on a 2024 Michigan DIFS external review case, BCBSM has strict medical policy criteria that must be met for approval, even after patients have tried multiple other medications.

Before You Start: Verify Your Coverage

Check Your Plan Type

  • Commercial plans: Follow standard PA process
  • Medicare Advantage: May have different formulary requirements
  • Medicaid (Healthy Michigan): Different appeal pathways apply

Confirm Emgality's Status

BCBSM typically places Emgality on a higher formulary tier requiring prior authorization. Check your specific plan's Clinical Drug List to confirm coverage status.

Verify Network Status

Ensure your prescribing physician is in-network and that you're using a BCBSM-preferred specialty pharmacy if required.

Step-by-Step: Fastest Path to Approval

1. Document Medical Necessity (Provider)

Timeline: Before submission

  • Record migraine frequency using a detailed headache diary
  • Document failure of ≥2 preventive medications from different classes
  • Use appropriate ICD-10 codes (G43 series for migraines)

2. Complete Prior Authorization Request (Provider)

Timeline: 1-2 business days

3. Include Required Documentation

Timeline: Same day as submission

  • Migraine diary showing ≥15 headache days/month
  • Prior therapy documentation with specific outcomes
  • Clinical notes supporting medical necessity

4. Track Your Request (Patient & Provider)

Timeline: Within 72 hours of submission

  • Standard review: Up to 15 business days
  • Expedited review: 24-72 hours if urgent criteria met
  • Document all reference numbers

5. Follow Up if Needed

Timeline: Day 10-12 after submission

  • Call BCBSM at member services number on your card
  • Ask for PA status and reference number
  • Request expedited review if medically urgent

What You Need to Gather

Medical Documentation

  • Migraine diary: 3+ months showing ≥15 headache days monthly
  • Prior therapy records: Names, doses, duration, outcomes
  • ICD-10 diagnosis: G43.711 (chronic migraine with aura) or appropriate code
  • Clinical notes: Supporting medical necessity

Insurance Information

  • BCBSM member ID and policy details
  • Prescriber NPI and contact information
  • Preferred pharmacy information

Prior Treatment Documentation

BCBSM typically requires documented failure of:

  1. Topiramate (anticonvulsant)
  2. Propranolol (beta-blocker) or similar
  3. Each tried for ≥6-8 weeks at therapeutic doses

How to Submit Your Request

Electronic Submission (Preferred)

  • CoverMyMeds: Integrated with most EHR systems
  • BCBSM Provider Portal: Direct submission option

Alternative Methods

  • Fax: 1-866-601-4425
  • Phone: 1-800-437-3803

Mail:

Pharmacy Services — Mail Code 512C
Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd.
Detroit, MI 48226-2998

Clean Submission Checklist

  • Complete PA form with all required fields
  • Migraine diary (3+ months)
  • Prior therapy documentation
  • Clinical notes with ICD-10 codes
  • Prescriber attestation if required

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Inadequate prior therapy Document 2+ failed preventives Drug names, doses, duration, outcomes
Insufficient migraine frequency Provide detailed headache diary 3+ months showing ≥15 days/month
Missing medical necessity Submit clinical notes ICD-10 codes, treatment goals, rationale
Quantity limits exceeded Request override or adjust dosing Clinical justification for higher dose
Not medically necessary Provide literature support FDA labeling, guidelines, peer-reviewed studies

Appeals Process in Michigan

If BCBSM denies your Emgality request, Michigan offers robust appeal rights:

Internal Appeal (First Level)

  • Timeline: File within 180 days of denial
  • Process: Submit through BCBSM member portal or by phone
  • Decision time: 30 days (expedited: 72 hours)

External Review via Michigan DIFS

  • Timeline: 127 days after final internal denial
  • Process: File online at DIFS External Review portal
  • Decision time: 60 days standard, 72 hours expedited
  • Outcome: Binding on BCBSM

Required Documentation for Appeals

  • Original denial letter from BCBSM
  • All medical records supporting necessity
  • Physician letter of medical necessity
  • For expedited: urgent medical need documentation

Contact DIFS: 877-999-6442 (Mon-Fri, 8 AM-5 PM)

Costs & Patient Assistance

Emgality Pricing

  • List price: ~$741.69 per 120mg pen
  • Cash price: $690-$870 with discount programs

Patient Assistance Options

  • Lilly Cares Foundation: Income-based assistance
  • Emgality Savings Card: Up to $150 off per prescription
  • Michigan Prescription Drug Programs: State assistance for qualifying residents

Clinician Corner: Medical Necessity Documentation

When submitting PA requests for Emgality, include:

Problem Statement

  • Chronic migraine diagnosis with ICD-10 code
  • Frequency and severity documentation
  • Impact on daily functioning

Prior Treatment History

  • Specific medications tried (topiramate, propranolol, etc.)
  • Doses, duration, and outcomes
  • Reasons for discontinuation

Clinical Rationale

  • Why Emgality is medically necessary
  • Expected outcomes and monitoring plan
  • References to FDA labeling or guidelines
From our advocates: We've seen the strongest approvals when providers include a detailed timeline showing exactly how long each prior medication was tried, the maximum tolerated dose, and specific reasons for failure. A simple statement like "failed topiramate due to cognitive side effects after 8 weeks at 100mg daily" carries much more weight than "topiramate ineffective."

FAQ

How long does BCBSM prior authorization take for Emgality? Standard review takes up to 15 business days. Expedited reviews for urgent cases are completed within 24-72 hours.

What if Emgality isn't on my formulary? You can request a formulary exception through the same PA process, providing medical necessity documentation and evidence of failed formulary alternatives.

Can I get an expedited appeal in Michigan? Yes, if delay would seriously harm your health. You'll need a physician letter documenting the urgency. DIFS expedited external reviews are decided within 72 hours.

Does step therapy apply if I tried medications outside Michigan? Yes, documented prior therapy from any state typically counts toward BCBSM's step therapy requirements.

What happens if DIFS overturns BCBSM's denial? The decision is binding. BCBSM must cover Emgality as directed by the independent review organization.

When to Escalate

Contact Michigan DIFS if:

  • BCBSM exceeds decision timelines
  • You believe the denial violates state insurance laws
  • You need help with the external review process

Michigan DIFS Consumer Services: 877-999-6442

For patients and providers navigating complex prior authorization requirements, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to craft point-by-point rebuttals aligned with each payer's specific requirements, helping streamline the approval process for medications like Emgality.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact BCBSM directly for plan-specific requirements. Coverage policies may change, so verify current requirements before submitting requests.

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