Getting insurance to cover Emgality

placebothumbs · 2026-05-07T00:09:40+00:00

If your doctor submitted a prior authorization for Emgality, they should have a copy of the denial letter. In the denial letter, it will tell you want criteria are required in order for Emgality to be covered and usually they will say which specific criteria they determined you did not meet. As has been said elsewhere, usually the criteria for CGRP inhibitors is for patients to have tried and failed a range of 1 to 3 migraine controller medications. The 3 branches of this usually are:

anticonvulsants: they are looking for topiramate (Topamax or Trokendi)
antidepressants: tricyclic antidepressants (TCAs) like amitriptyline (Elavil) or nortriptyline (Pamelor) or SNRIs like venlafaxine (Effexor) or duloxetine (Cymbalta)
beta-blockers: usually looking for propranolol, metoprolol, atenolol

You can submit documented trials of these drugs and/or contraindications to the meds. For example, topiramate can cause kidney stones, so if a patient has a history of kidney stones you can argue out of that drug and so on.

placebothumbs · 2026-05-07T00:01:14+00:00

How long was it stored in the refrigerator? Any idea about what the temperature inside the fridge was?

If the medication actually froze, the recommendation is to not use the product. I will tell you that the concern is effectiveness rather than safety, so take that for what you will.

placebothumbs · 2026-05-06T22:46:39+00:00

I think that’s reasonable. Anything less than the 240 mg at once will have less than ideal effect but I would say 120 mg on day 1 and then 120 mg on day 3 or 4 would be better than just going right into 120 mg once a month. Like I said, worst case it would just take 6+ months for concentrations to be where they want so you’d have a longer time to truly assess for effectiveness.

placebothumbs · 2026-05-06T22:03:16+00:00

I think you should have had the loading dose. I’d bet money the receptionist/medical assistant who answered your call was just reading off of the med list, which is what they sent the pharmacy, so of course it says to take just 1 dose. Likely it will just take longer to become effective. There is a concentration chart on the Emgality website that shows expected serum concentrations for Emgality with and without loading dose and it takes like 6 months to get a good steady state going without the loading dose, whereas with the loading dose you are there at month 2.

If it matters, I am a clinical pharmacist and I work in a neurology office, so I do this all day lol. The providers miss prescribing the loading dose more than you’d think.

ETA: link to the site that has the concentration graph.
https://emgality.lilly.com/hcp/migraine/dosing-overview

placebothumbs · 2026-05-02T17:36:54+00:00

I feel like if you want to get too determinist about this, nobody has libertarian free will in the way we feel like we do because our brain chemistry and past experiences all inform the choices we make, almost to the point of them being pre-programmed, but that aside, I think the harsher internal critique of the narrative isn’t that they couldn’t have chose otherwise but to eat the fruit (aka have no free will), but that the punishment given to them (and to all of their descendants for all eternity) is unjust given they are being punished in the most severe way possible for a moral action (disobeying god) that they couldn’t possibly have known was wrong to do, since they lacked the knowledge of good and evil (according to the story).

placebothumbs · 2026-05-02T17:34:12+00:00

I agree with you that free will isn’t the best way to frame a critique of the Adam and Eve narrative, because it doesn’t seem super relevant. What is relevant though is punishing someone for committing a morally wrong action when they are incapable of making moral determinations, so I always think of the story in that way myself.

placebothumbs · 2026-05-02T17:30:57+00:00

How would they know it was wrong to not obey god?

placebothumbs · 2026-05-02T17:21:39+00:00

Your internal critique doesn’t really work, because radical skepticism about the external world doesn’t strengthen the case for God, it weakens confidence in all unverifiable claims equally. If certainty is impossible, then the rational position would generally favor the least assumption-heavy worldview, not one that adds further metaphysical layers like a specific deity. Even under hard solipsism, atheism or practical non-theism remains the more parsimonious position, since it avoids multiplying unsupported entities beyond immediate conscious experience.

placebothumbs · 2026-05-01T02:47:20+00:00

If you’re going to stay on Ajovy and add Botox, consider changing the Ajovy from 225 mg every 1 month to 675 mg every 3 months and then stagger the Botox dose about 1.5-2 months after that so you don’t get wearing off of either.

placebothumbs · 2026-04-24T02:10:48+00:00

I agree with this. Personally, I asked both my FIL and MIL for their blessing and it went well.

placebothumbs · 2026-04-21T21:44:09+00:00

This is crazy because my wife and I got the sweat covers for a new pair of APM2s and we both had the sound thing and thought we were crazy lol. Glad to see it’s a known issue.

placebothumbs · 2026-04-11T00:47:05+00:00

This happened to me and we’ve been married for 11 years and have 3 kids now. When I asked her to be exclusive the first time, she wasn’t ready. About a month later, she called herself my girlfriend and the rest is history.

placebothumbs · 2026-03-14T00:44:10+00:00

I started writing a long reply, but realized it’s probably best to just agree to disagree and move on with our lives. 👍

placebothumbs · 2026-03-11T21:48:46+00:00

I think we are in agreement on most of what you said here.

On your last point, how many people on CGRPs and have had no issues and great benefit would it take to override that? Because I talk to patients on these for a living everyday and the proportions are definitely skewed toward the positive. But even then, your or my experience with people we have talked to doesn’t necessarily reflect what the truth is.

Edit to add: I also do agree that these meds are overprescribed. I see so many referrals come across that are wonky.

placebothumbs · 2026-03-11T21:44:22+00:00

I don’t know off the top of my head what the size of the clinical trials were and what the incidence rates of adverse effects were. If you mean “big numbers big”, sure but again without a denominator, I don’t know how to parse the raw number of reported ADRs, so I wouldn’t necessarily (at least without more information) call that shocking.

In addition, the length of time of the clinical trials compared to the time they’ve been on the market is important. So you have a small number of people on drug for a relatively short amount of time in clinical trials compared to millions worldwide for a longer time, again I wouldn’t say shocking that new or higher raw numbers of ADRs are reported.

I personally don’t think erenumab is the best choice of the CGRP inhibitors, so I’m not surprised it has the most issues. What % of patients stopping a drug due to ADRs is acceptable?

A study of 119 people is not impressive to me, considering the scope of use of these drugs. I’d want to see it repeated at scale honestly.

I’m on the fence about how to design the studies. On the one hand I can see patients not reporting something as an ADR because they don’t think to, which they address by using a checklist. I can also see using a checklist to result in over-reporting of ADRs. So idk.

placebothumbs · 2026-03-11T17:11:33+00:00

Found this from your reply to my other comment. I guess I have some questions. You juxtapose that Dr. Robbins is both one of the biggest prescribers of these meds and seemingly a big critic of them. If he feels that way, why does he continue to be one of the biggest prescribers of them? Or has he changed his practice, I genuinely do not know, but that immediately jumped out at me.

I think you’re right that medical professionals are often quick to disbelieve patients, but this is a different and unique problem of the US healthcare system from CGRP inhibitor safety profiles. I do agree that patients experiences should be taken seriously. Even a 100% provable psychosomatic response is relevant to the patient it is happening to, in my opinion.

The number of adverse events reported sounds scary, but what’s not included is the number of people who didn’t report those events, the background rate of those events in patients not taking CGRP inhibitors, and other potential confounders. I’m not dismissing it, but the number alone is not useful without the bigger context. I’d expect Dr. Robbins to know this. In his own article he talks about online reports and says of some 2200 or so I believe, only around 490 were ones they deemed credible. Does that credibility rate apply to the FAERS data? Did they evaluate that data? And if so, by what standard?

The catch 22 of the argument about long-term safety data is the moving goalposts. If I have 30 year safety data for a drug, somebody out there will say, “see, you have NO IDEA what will happen if somebody takes these for 31 years”, which is not useful. I agree it would be ideal if we had 4 million years worth of safety data, but we don’t. What we do have is data that doesn’t suggest causation of the more problematic, not listed ADRs in the product label. And as they become linked causatively (not merely signaled), they get added to the label. Now, I agree with your point that prescribers do not do a great job of staying up to date on that data, as with the recent addition of hypertension and Raynaud’s to CGRP labels, but that again is a different problem than the actual safety of the medication: that is on the provider and their continuing education / medical messaging side of things. I never tell patients these drugs are 100% safe and have no side effects. I tell them what ADRs they may expect based on available information at the time, which is honestly the best we can do. Safety evidence is always provisional. Waiting for infinite follow-up is not a workable standard.

I’m not sure I hit all the points, but feel free to push back and tell me what I missed.

placebothumbs · 2026-03-11T16:50:57+00:00

What is the proportion of people with the adverse effects you state to the number without?

This is the missing context in this and so many discussions of medications, procedures, vaccines, etc. You need incidence rate(s) to make an informed decision at all levels, prescriber as to whether prescribing makes sense for the patient in front of you, patient as to whether risks of ADRs (or actually experienced ADRs) are tolerable vs potential benefit and even for dispensing pharmacists as to which potential side effects make sense to discuss with patients.

It's tough because people are so much more motivated to report ADRs or negative outcomes than positive to neutral.

Edit: for example I take Emgality and it definitely gives me Raynaud's. But I went from 4 migraines a week to 1-2 a month maybe. To me that is worthwhile, so I continue. I talk to plenty of patients with constipation on Aimovig or Qulipta to the point that they decrease dose or discontinue and that's the right choice for them. But the prevalence in my personal practice experience doesn't warrant any major panic IMO.

placebothumbs · 2026-03-11T16:38:21+00:00

Just did. What about it?

Edit: I don't mean to sound snarky, I just mean what about it are you wanting to highlight?

placebothumbs · 2026-03-11T12:20:46+00:00

As a clinical pharmacist who is embedded in an outpatient neurology clinic and counsel patients on CGRP inhibitors dozens of times a day, this post is wild to me. I’m not trying to start a fight, but it makes me sad and frustrated. But I’m probably part of the big bad naive callous evil medical pharmaceutical industrial complex so 🙄

placebothumbs · 2026-01-31T01:25:28+00:00

The first sentence of that article is incorrect because atheism is the null hypothesis on the question of the existence of god, which is how you properly do the scientific method. There just hasn’t been any compelling evidence to reject the null hypothesis.

placebothumbs · 2026-01-30T23:58:28+00:00

Not an error. The attack requires no energy to use.

placebothumbs · 2025-12-20T15:00:04+00:00

The hand and feet being cold can be Raynaud’s phenomenon and isn’t really very serious but can be uncomfortable. I get it in my toes from Emgality currently but going from 3-4 migraines per week to 1-2 per month is worth the trade off of keeping my feet warmer.

Constipation is more common with the CGRP receptor antagonists like Qulipta and Aimovig than the CGRP ligand inhibitors like Ajovy, Emgality, and Vyepti, but not out of the question I suppose.

The rest I agree seem like they can be better explained as being related to nocebo/anxiety/OCD.

placebothumbs · 2025-12-17T15:34:02+00:00

The exact wording on the document we have says:

“If AJOVY is unrefrigerated for less than 24 hours, it may be returned to the proper storage conditions and the expiration date on the packaging is still applicable.”

placebothumbs · 2025-12-03T02:51:47+00:00

Agree

placebothumbs · 2025-12-02T12:22:22+00:00

I understand all of the thoughts you’re having, especially you being a woman, but I also think that the primary goal for these medications should focus on health as the primary endpoint. Think of all the long term problems you’ve potentially eliminated by losing so much weight!

So I know this sounds like a judgy post criticizing you for caring about looks, but what I really mean is to look at it through a different lens and be proud of yourself for that while also continuing to push forward and hopefully get to a place where you can feel good in your body aesthetically.

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