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

The Requirements Checklist to Get Emgality Covered by Blue Cross Blue Shield in New Jersey

Answer Box: Your Path to Emgality Coverage

To get Emgality (galcanezumab) covered by Blue Cross Blue Shield in New Jersey: You'll need prior authorization showing failure of 2+ preventive medications (like topiramate, propranolol) for migraine or cluster headache. Submit PA via your Horizon BCBS provider portal with ICD-10 codes G43.x (migraine) or G44.0 (cluster headache). If denied, appeal internally first, then file for free external review through New Jersey's IHCAP program within 4 months. Success rates are high with proper documentation.

Start today: Have your doctor gather records of failed preventive treatments and submit the PA request electronically.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Information
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Coordination
  8. After Submission: What to Expect
  9. Common Denial Prevention Tips
  10. Appeals Process in New Jersey
  11. Quick Reference Checklist

Who Should Use This Guide

This comprehensive checklist is designed for patients with migraine or cluster headache who need Emgality (galcanezumab) covered by Blue Cross Blue Shield plans in New Jersey, along with their healthcare providers. You'll benefit most if you:

  • Have episodic or chronic migraine (≥4 migraine days per month)
  • Experience episodic cluster headache during active cluster periods
  • Have tried and failed at least 2 standard preventive medications
  • Are working with a neurologist or headache specialist
  • Hold a fully-insured Horizon BCBS or other New Jersey Blue Cross plan

Expected outcome: With proper documentation, most patients meeting clinical criteria get approved. If initially denied, New Jersey's external review program has strong success rates for medically necessary treatments.

Member & Plan Basics

Verify Your Coverage Status

Before starting the prior authorization process:

Check these basics:

  • Confirm active Blue Cross Blue Shield coverage through your member portal
  • Identify your specific plan type (commercial, Medicare Advantage, Medicaid managed care)
  • Review your current deductible status and specialty drug coverage
  • Verify Emgality requires prior authorization on your plan's formulary
Note: Self-funded employer plans may follow different rules than fully-insured New Jersey plans. Check your Summary of Benefits and Coverage (SBC) or call member services.

Plan-Specific Requirements

Plan Type Key Details Coverage Notes
Horizon BCBS NJ PA required; Tier 5 specialty Must use in-network specialty pharmacy
Medicare Advantage PA + step therapy typical May have quantity limits
NJ Marketplace Varies by metal tier Check specific formulary PDF

Clinical Criteria Requirements

FDA-Approved Indications

Emgality is approved for:

  • Migraine prevention in adults: 240 mg loading dose, then 120 mg monthly
  • Episodic cluster headache: 300 mg monthly during cluster periods

Step Therapy Documentation

You must document failure of 2+ preventive medications from these categories:

Level A/B Preventives (commonly required):

  • Beta-blockers: propranolol, nadolol, atenolol
  • Antiepileptics: topiramate, valproate
  • Tricyclics: amitriptyline, nortriptyline
  • SNRI: venlafaxine

Documentation requirements for each failed medication:

  • Specific drug name and maximum tolerated dose
  • Duration of adequate trial (typically 8-12 weeks)
  • Reason for discontinuation (ineffective, intolerable side effects, contraindication)
  • Pharmacy records or clinical notes confirming the trial

Clinical Thresholds

For migraine prevention:

  • ≥4 migraine days per month documented over 3+ months
  • Headache diary showing frequency and impact
  • ICD-10 diagnosis: G43.001-G43.819 (episodic/chronic migraine)

For cluster headache:

  • Active episodic cluster period
  • ICD-10 diagnosis: G44.0 (cluster headache)

Coding and Billing Information

Essential Medical Codes

Code Type Code Description
ICD-10 G43.x Migraine (various subtypes)
ICD-10 G44.0 Cluster headache
HCPCS J3590 Unclassified biologics
NDC 0002-1436-11 120 mg prefilled pen (single)
NDC 0002-1436-27 120 mg prefilled pen (2-pack)

Billing Considerations

  • Emgality is covered under pharmacy benefit for self-administration
  • No specific modifiers required for standard billing
  • Contact your Blue Cross plan for current J-code acceptance

Documentation Packet Essentials

Medical Necessity Letter Components

Your physician's letter should include:

Patient Information:

  • Full name, date of birth, member ID
  • Current migraine frequency with specific examples
  • Functional impact on work, daily activities

Clinical History:

  • Detailed documentation of failed preventive trials
  • Contraindications to standard therapies (if applicable)
  • Current medication list and allergy history

Medical Evidence:

  • Reference to FDA prescribing information
  • Citation of American Headache Society guidelines supporting CGRP inhibitors
  • Clinical rationale for Emgality specifically

Required Attachments Checklist

  • Completed prior authorization form
  • Medical necessity letter from prescribing physician
  • Headache diary (3+ months of documentation)
  • Pharmacy records showing failed preventive trials
  • Clinical notes documenting diagnosis and treatment history
  • Insurance card copy
Tip: Organize documents chronologically and highlight key information like medication names, dates, and failure reasons.

Submission Process

Electronic Submission (Preferred)

For Horizon BCBS providers:

  1. Log into the Horizon Provider Portal
  2. Search for Emgality using HCPCS code J3590
  3. Complete the electronic PA form with required clinical information
  4. Upload supporting documents
  5. Submit and record confirmation number

Timeline: Electronic submissions typically process within 3-5 business days.

Alternative Submission Methods

If electronic submission isn't available:

  • Fax: Use plan-specific fax number (verify current number on provider portal)
  • Mail: Send to address listed on PA form
  • Phone: For urgent/expedited requests only

Common Form Rejection Reasons

Avoid these frequent mistakes:

  • Incomplete patient demographics
  • Missing ICD-10 diagnosis codes
  • Inadequate step therapy documentation
  • Unsigned medical necessity letter
  • Wrong PA form version

Specialty Pharmacy Coordination

Network Requirements

Blue Cross Blue Shield plans in New Jersey typically require specialty medications like Emgality to be dispensed through contracted specialty pharmacies:

Common network pharmacies:

  • Accredo Specialty Pharmacy
  • AllianceRx Walgreens Pharmacy
  • CVS Specialty Pharmacy

Post-Approval Process

Once your PA is approved:

  1. Your prescriber sends the prescription to the assigned specialty pharmacy
  2. Pharmacy contacts you to set up delivery and counseling
  3. First dose may include injection training
  4. Ongoing refills coordinated automatically
Note: Retail pharmacies typically cannot fill Emgality due to specialty drug network requirements.

After Submission: What to Expect

Confirmation and Tracking

Record these details:

  • PA confirmation number
  • Submission date and method
  • Expected decision timeline
  • Contact information for status checks

Status Check Schedule

  • Day 3: Verify receipt if submitted electronically
  • Day 7: Check status if no response received
  • Day 14: Follow up if approaching decision deadline
  • Day 21: Prepare appeal documentation if denied

Decision Notifications

Approvals typically include:

  • Coverage duration (usually 6-12 months initially)
  • Quantity limits and refill authorization
  • Specialty pharmacy assignment

Common Denial Prevention Tips

Five Critical Pitfalls to Avoid

  1. Insufficient step therapy documentation
    • Fix: Provide detailed pharmacy records with dates, doses, and specific failure reasons
  2. Vague functional impact description
    • Fix: Include concrete examples of work missed, activities limited, emergency visits
  3. Missing or incorrect diagnosis codes
    • Fix: Use specific ICD-10 codes (G43.x for migraine, G44.0 for cluster)
  4. Outdated clinical information
    • Fix: Ensure all documentation is within the past 6 months
  5. Incomplete medical necessity justification
    • Fix: Reference FDA labeling and clinical guidelines supporting CGRP inhibitor use

Pro Tips for Success

  • Partner with a neurologist or headache specialist familiar with CGRP inhibitor approvals
  • Maintain detailed headache diaries throughout the process
  • Request peer-to-peer review if initially denied
  • Consider Counterforce Health's platform to help draft targeted appeals that address your plan's specific denial reasons

Appeals Process in New Jersey

Internal Appeals (Required First Step)

Horizon BCBS internal process:

  • Stage 1: Up to 10 calendar days (72 hours if expedited)
  • Stage 2: Up to 20 business days (72 hours if expedited)
  • Submit appeals through provider portal or member services

External Review Through IHCAP

If internal appeals are unsuccessful, New Jersey offers free external review through the Independent Health Care Appeals Program (IHCAP).

Key details:

  • Administrator: Maximus Federal Services
  • Filing deadline: 4 months from final internal denial
  • Timeline: 45 days for standard review, 48 hours for expedited
  • Cost: Free to patients and providers
  • Success rate: Approximately 50% of external appeals favor consumers nationally

IHCAP Submission Requirements

Submit to Maximus:

  • Completed external appeal application
  • All internal appeal denial letters
  • Medical records and physician documentation
  • Patient consent (if provider-initiated)

Contact for assistance:

  • NJ DOBI Consumer Hotline: 1-800-446-7467
  • IHCAP Hotline: 1-888-393-1062
From our advocates: "We've seen many New Jersey patients succeed with IHCAP external reviews for specialty migraine medications. The key is thorough documentation showing medical necessity and failed alternatives. One patient's Emgality denial was overturned within 3 weeks when their neurologist provided detailed notes about medication overuse headache risks with other preventives."

Quick Reference Checklist

Before Starting

  • Verify active Blue Cross Blue Shield coverage
  • Confirm Emgality requires PA on your formulary
  • Gather 3+ months of headache diary documentation
  • Collect pharmacy records of failed preventive trials

Clinical Documentation

  • ICD-10 code: G43.x (migraine) or G44.0 (cluster headache)
  • Document ≥2 failed preventive medications with specific details
  • Medical necessity letter addressing FDA indications
  • Current medication list and contraindications

Submission Package

  • Complete PA form with all required fields
  • Signed medical necessity letter
  • Supporting clinical documentation
  • Insurance card copy
  • Submit via provider portal (preferred) or fax

After Submission

  • Record confirmation number and submission date
  • Schedule status check in 5-7 days
  • Prepare for specialty pharmacy coordination if approved
  • Plan appeal strategy if denied

If Denied

  • Request specific denial reasons
  • File internal appeal within required timeframe
  • Gather additional supporting documentation
  • Consider external IHCAP review if internal appeals fail

Need help navigating the appeals process? Counterforce Health specializes in turning insurance denials into successful appeals by analyzing your plan's specific policies and crafting targeted rebuttals with the right clinical evidence and procedural requirements.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical advice. Coverage decisions depend on individual medical circumstances and specific insurance plan terms. Always consult with your healthcare provider about treatment options and work with your insurance plan directly for coverage determinations. For assistance with New Jersey insurance appeals, contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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