Article
The Current Landscape of CGRP Inhibitor Coverage
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In the United States, nearly 50 million Americans suffer from migraine, the majority of whom are between 25 to 55 years of age. The costs of treating this large population have been estimated to be $22 billion annually. A new report, published by the Pharmacy Benefit Management Institute, found that direct healthcare costs for patients with migraine were estimated at $2571 higher than those for similar patients who don’t experience migraine.
In the United States, nearly 50 million Americans suffer from migraine, the majority of whom are between 25 to 55 years of age. The costs of treating this large population have been estimated to be $22 billion annually.
A new report, published by the Pharmacy Benefit Management Institute (PBMI), found that direct healthcare costs for patients with migraine were estimated at $2571 higher than those for similar patients who don’t experience migraine. Furthermore, not only do patients with migraine experience greater healthcare costs, but their employers also feel residual effects from the disease, as well. According to the report, “workers with migraine cost employers an additional $2834 in lost productivity compared with those who do not suffer from migraine.” Indirect costs from reduced productivity and workers unable to attend work are estimated to reach $12 billion annually.
The diagnosis of migraine requires patients to experience at least 5 headache attacks that meet the following criteria: a headache that lasts 4 hours to 72 hours, nausea and/or vomiting or an extreme sensitivity to light and sound, unilateral in location with moderate to severe pain with pulsating qualities, and aggravated by or causing the patient to avoid physical activities. The report also noted that Americans aged 12 years and older have an 11.7% annual prevalence of migraine, with women experiencing much higher rates than men (17.1% vs 5.6%, respectively).
In May 2018, the first biologic therapy specifically for the prevention of migraine received FDA approval. The therapy, erenumab-aooe (Aimovig), a calcitonin-gene-related peptide (CGRP) is a once-monthly, self-injected treatment that costs an estimated $6900 per year. By September 2018, 2 other CGRP inhibitors had also received FDA approval.
PBMI’s report noted that in a survey of patients diagnosed with migraine that was conducted in spring 2018, only one-third of patients were aware that CGRP inhibitors exist as a treatment option. Though plan sponsors had a higher awareness of CGRP inhibitors, most patients surveyed reported that their insurance plan covered traditional preventive and acute treatment medications (79% and 76%, respectively, n = 306), while less than half currently covered specialty medications with 48% covering Botox injections and 22% covering CGRP inhibitors.
Plan sponsors employ several clinical and utilization programs for migraine, including step therapy, which requires a patient to use a less expensive drug (in this case, a ‘nonspecialty agent’) and experience no clinical benefit prior to moving to another, more expensive medication (69%); prior authorization based on migraine frequency (60%); prior authorization based on migraine severity (55%); and step therapy that requires the trial of at least 2 different nonspecialty agents from 2 different drug classes (43%).
PBMI asked plan sponsors what outcomes they wished to see from CGRP inhibitors in order to inform future drug benefit decisions. Half or more of total respondents (n = 306) reported improvement in the number of migraine days, improvement in migraine severity, reduced use of narcotic analgesics, and improvements in emergency department/urgent care use.
In terms of insurance coverage, the report found that as more CGRP inhibitors receive FDA approval and come to market, plan sponsors will need to “evaluate and adjust current benefit designs to best meet the needs of their organization and members.”
