Coverage for CGRP Receptor Antagonists for Migraine

Peter L. Salgo, MD: What are your coverage criteria for using these CGRP [calcitonin gene-related peptide] receptor antagonists? What do you require?

Malaika Stoll, MD, MPA: It’s similar to Botox, so we want them to try a couple of other preventive methodologies. If those don’t work, then we would like a prior authorization.

Peter L. Salgo, MD: So, you need a prior authorization. And, not unreasonably, you want some step therapy. In other words, if aspirin works, why go further.

Malaika Stoll, MD, MPA: Right.

Peter L. Salgo, MD: Because aspirin is cheap and can be accessed over the counter.

Malaika Stoll, MD, MPA: Right. In this case, it would be preventive therapy. So, the beta-blockers and…

Peter L. Salgo, MD: The phrase “prior authorization” rolls off your tongue like honeydew drops.

Malaika Stoll, MD, MPA: I could just say “auth.” Does that sound better?

Peter L. Salgo, MD: No, it sounds awful, truly. In this regard, it sounds like paperwork. It sounds like a lot of back-and-forth and having to explain yourself when all the person wants is a drug that works.

Malaika Stoll, MD, MPA: Right.

Peter L. Salgo, MD: How cumbersome is it to get a prior authorization for one of these new drugs?

Jill Dehlin, RN: Well, it’s a relatively new drug. It just came out at the end of May, right? Right now, the biggest issue for people who are trying to get the drug is that the demand is so great and it’s difficult to get.

Peter L. Salgo, MD: Are you saying that supply is an issue?

Jill Dehlin, RN: Yes.

Peter L. Salgo, MD: Is that going to drive cost up?

Jill Dehlin, RN: No.

Peter L. Salgo, MD: Why not?

Jill Dehlin, RN: Because they promised us.

Malaika Stoll, MD, MPA: I think they set the prices, right?

Jill Dehlin, RN: Yes, the prices are set.

Peter L. Salgo, MD: Who set them?

Jill Dehlin, RN: Amgen.

Peter L. Salgo, MD: OK. And they’re going to stick to it?

Jill Dehlin, RN: Yes.

Peter L. Salgo, MD: All right. So, we can’t overload the pipeline because there’s not enough to go around. Is that what I’m hearing you say?

Jill Dehlin, RN: I didn’t say we shouldn’t overload the pipeline.

Peter L. Salgo, MD: But we could.

Jill Dehlin, RN: Yes, we could.

Peter L. Salgo, MD: Clearly, you live in the land of Oz and your program is perfect. But for others, not so much. Do your patients have appropriate access to these drugs and have you heard of other areas where they don’t?

Jill Dehlin, RN: As I mentioned before, there are plans that are requiring UCNS [United Council for Neurologic Subspecialties]—certified physicians to prescribe them. By and large, though, the application process is fairly straightforward.

Peter L. Salgo, MD: What about formularies? It’s one thing to do this on a one-off basis. Do you plan on approving this in formularies and just having scripts for it going forward?

Malaika Stoll, MD, MPA: Well, they are part of the formulary now. But, as we discussed, you have to try a couple of the other more established agents first to meet the criteria for these. But, as I mentioned before, I do think that access can be an issue, even in a state that has certified neurologists. So, I do still worry about patients, or members, not necessarily getting the medications they need. I think that’s a universal issue.