Why do plans require older migraine preventives first?

Because step therapy is a cost-control rule and the older preventives are inexpensive. Coverage policies for CGRP monoclonal antibodies commonly require documented trials of a number of conventional preventive agents, from classes such as beta blockers, antiepileptics and antidepressants, before the newer drug becomes available.

I stopped a preventive because of side effects, not because it failed. Does that count?

Documented intolerance is a recognised exception ground in most step policies, and it is treated differently from a failure of effect. What it requires is a record: the drug, the dose, the reaction, and the visit or note where it was reported.

Why does the plan want a headache diary?

Because criteria in this class are usually written around headache days per month over a defined baseline period, and a diary is how that number is evidenced. Charts often describe frequency loosely, which is enough for care and not enough for a coverage criterion.

My neurologist says the older drugs are contraindicated for me. Is that enough?

It can be a valid exception ground, but it has to be claimed explicitly and supported by the record that establishes the contraindication, such as the comorbid condition, the interacting medication or the documented reaction. A general statement without the supporting record is the most common reason these requests fail.

Does a denial of one CGRP drug mean all of them are denied?

Not necessarily. Plans often prefer one product in the class and require an exception for the others, so a denial may be about product preference rather than the class. The notice should name which, and the plan's formulary confirms it.

CGRP migraine injections denied: Aimovig, Emgality and Ajovy

Cove Health·August 31, 2026

Preventive CGRP injectables are denied more often than most patients expect, and almost always for one of two documentary reasons: the plan requires older preventive drugs to be tried first and the record does not show them, or the criteria are written around headache frequency and nothing in the file establishes the number. Neither is a judgment about whether you need the treatment.

Why was my CGRP injection denied?

Step therapy. Coverage policies commonly require documented trials of conventional preventives, usually from more than one class, each at an adequate dose and for an adequate duration, before a CGRP antibody is covered. Trials that happened years ago, or under a different insurer, are frequently invisible to the plan applying the rule today.

Headache frequency was not evidenced. Criteria typically reference migraine or headache days per month across a baseline period. Without a diary or a note that records the count, the criterion cannot be verified even where it is plainly met.

Diagnosis or specialty requirements. Some policies require the diagnosis to be recorded in a particular form, distinguish episodic from chronic migraine, or require the prescription to come from or be endorsed by a specialist.

Product preference. Where the plan prefers a different agent in the class, the denial is about which product, not whether. That is answered as a formulary exception.

Concurrent therapy limits. Plans often will not cover two preventives in this class at once, or restrict combinations with other agents, and a request that reads as a combination can be denied on that ground alone.

What does the denial letter actually mean?

"Step therapy required" means the plan named drugs it wants tried first, and the appeal is a step therapy override claiming a specific exception ground: already tried and failed, intolerance, contraindication, expected ineffectiveness, or stability on the current regimen.

"Criteria not met" means the policy exists and the submission did not establish a point in it, most often the headache-day count or the documented prior trials. "Quantity limit" means the dose or supply requested sits outside the plan's limit. "Non-formulary" or "non-preferred" points at an exception request rather than a clinical dispute.

The notice must give you the reason, the deadline and the address to appeal to. Those are the authority on your case.

What can I do in the next 48 hours?

The general sequence is in the first 48 hours after a denial. For this class, three things move the case.

Ask the plan in writing for the coverage policy and the step protocol it applied. Ask your prescriber's office for the record of every preventive tried: drug, dates, dose, titration, and why it was stopped, along with the note where any side effect was reported. Start or retrieve a headache diary, because the criteria are usually written in headache days and a contemporaneous record is the cleanest way to evidence them.

If you are not sure which route the notice points to, the free denial check sorts it in about a minute.

How does a physician-written appeal help for CGRP denials?

The argument here is documentary and clinical at the same time: it has to name the plan's step or criterion, then show the record that satisfies it. A licensed physician reads the records, says candidly whether the case has merit, and where it does writes a letter that claims the specific override ground the plan's own policy provides, sets out the preventive trial history with dates, doses and outcomes, evidences the headache burden in the terms the criteria use, and cites the guidelines and labeling behind the prescribed agent.

Cove Health cannot guarantee results, but you should not have to assemble that file alone.

Cove Health provides advocacy services. Information on this site is general information, not legal or medical advice. Cove Health is not a law firm and does not provide legal representation, and submission of records does not guarantee a particular outcome.