ANTIMIGRAINE AGENTS: OTHER | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
AIMOVIG 140 MG/ML AUTOINJECTOR erenumab-aooe	55513084301 AMGEN	Yes	No	Medicaid CHIP CSHCN
AIMOVIG 70 MG/ML AUTOINJECTOR erenumab-aooe	55513084101 AMGEN	Yes	No	Medicaid CHIP CSHCN
AJOVY 225 MG/1.5 ML AUTOINJECT fremanezumab-vfrm	51759020210 TEVA USA	Yes	No	Medicaid CHIP CSHCN
AJOVY 225 MG/1.5 ML SYRINGE fremanezumab-vfrm	51759020410 TEVA USA	Yes	No	Medicaid CHIP CSHCN
EMGALITY 120 MG/ML PEN galcanezumab-gnlm	00002143611 ELI LILLY & CO.	Yes	No	Medicaid CHIP CSHCN
EMGALITY 120 MG/ML SYRINGE galcanezumab-gnlm	00002237711 ELI LILLY & CO.	Yes	No	Medicaid CHIP CSHCN
NURTEC ODT 75 MG TABLET rimegepant sulfate	72618300002 BIOHAVEN PHARMA	Yes	No	Medicaid CHIP CSHCN
UBRELVY 100 MG TABLET ubrogepant	00023650110 ALLERGAN INC.	Yes	No	Medicaid CHIP CSHCN
UBRELVY 100 MG TABLET ubrogepant	00023650116 ALLERGAN INC.	Yes	No	Medicaid CHIP CSHCN
UBRELVY 50 MG TABLET ubrogepant	00023649810 ALLERGAN INC.	Yes	No	Medicaid CHIP CSHCN