July 06, 2018
I imagine that most everyone employed within managed care had a similar moment of terror the first time we heard about the pipeline development of calcitonin gene-related peptide (CGRP) receptor antagonists for the treatment of migraines. Most of the CGRP antagonist drugs we were hearing about are monoclonal antibody biologic agents. To date, biologic medications were virtually synonymous with specialty medications along with the price tag that comes along with that designation. I heard a number of managed care professionals speak of their dread considering what the release of these medications could mean for payer budgets. Applying a specialty priced medication to a population as large as migraine suffers had the potential to crush the economics of drug spend for many plans.
I could then almost hear a collective sigh of relief when the first CGRP antagonist, Aimovig (erenumab), recently came to market and the pricing was released. Although the listed AWP of $690 per month supply is higher than the price of many of the recent blockbuster small molecule drugs, it is a far cry from many of the recently release biologic medications with prices exceeding $3000. Although I do not know all of the discussion Amgen went through to come up with their initial list price, it seems like they may have taken into account the feedback many payers were giving them regarding the impact high prices would make on budgets and the strict management that would come along with that kind of pricing.
From a managed care and budget perspective, I think the release and pricing of Aimovig sets a positive stage for this class of medications. With expected PDUFA dates on Teva's fremanezumab and Eli Lilly's galcanezumab in September there will likely be a rush between payers and manufacturers to rebate on these products for preferred formulary status. The pricing and imminent competition within this new class of drugs should allow a nice balance of coverage and management for the interest of all parties including patients, payers, and manufacturers.
From the payer perspective a starting price of these drugs outside of specialty pricing, along with the likely upcoming rebates, means that these drugs will not have the magnitude of impact on budgets we feared. I predict this pricing will lead to less management of this category than we had anticipated. I would not be surprised if some plans even manage this class with simple step therapy requirements, or at most a simple prior authorization with criteria just to product label, in exchange for the right rebate offer. This is a win for manufactures as it will allow for increased utilization earlier in the product life.
While the payer and manufacturer considerations are important, these kinds of management strategies are an even bigger win for patients. There are a number of patients who suffer from regular migraines and the decreased productivity that accompanies a migraine attack but have not found relief in the drugs that have been available until now. Allowing this group of patients to have easier access to this new class of medication will be life changing for many of them.
I am a strong advocate of all stakeholders coming together to find ways to make needed therapies available for patients in ways that will not cripple health care budgets, and I think I see that happening within the CGRP antagonist class. The stage is set for a positive outcome for all interested parties. The initial terror many of us felt when first considering biologics for the treatment of migraines has subsided which I see leading to better outcomes for payer budgets, manufacturer interests, and most importantly patient access.
Russ J Spjut, PharmD, is owner of Formulary Intel Consulting. He is a residency trained pharmacist in managed care with experience in both commercial and Medicare Part D PBM operations. He has been involved in formulary management, P&T committee presentations, clinical program development, formulary strategy, clinical analysis, client management, and review of coverage determination requests for a major health care management company.
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