MMIT Reality Check on Migraine Prevention

Payer Coverage:

A review of market access for preventive migraine treatments shows that under the pharmacy benefit, about 53% of the lives under commercial formularies are covered with utilization management restrictions. Around 45% of the lives under Medicare formularies are not covered for at least one of the drugs.

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Under the medical benefit, about 85% of the lives under commercial policies are covered with utilization management restrictions. Almost 47% of the lives under Medicare Part B policies have access to at least one of the drugs without utilization management restrictions.

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For about 40% of the covered lives, payer pharmacy benefit formularies do not require step therapy (ST). Of the lives that require ST, about 70% require multiple steps. Around 70% of payer-controlled pharmacy benefit covered lives require prior authorization, with 29% of those lives covered by policies that are restrictive as compared with a product’s FDA-approved label.

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Trends:

FDA Approves AbbVie’s Qulipta in Migraine Prevention

In September 2021, the FDA approved AbbVie Inc.’s CGRP inhibitor Qulipta (atogepant) for the prevention of episodic migraine, with analysts already calling the drug a blockbuster-to-be. Qulipta will have to face off against Biohaven’s Nurtec ODT, the first oral CGRP inhibitor approved in the migraine space. For migraine prevention, Nurtec holds covered or better status for 77% of all insured lives under the pharmacy benefit and is not covered for 19.2% of lives, as of October 2021.

FDA Approves Nurtec ODT

In May 2021, the FDA approved Biohaven Pharmaceutical Holding Company Ltd.’s Nurtec ODT (rimegepant 75 mg) for preventive treatment of episodic migraine in adults. It was the first oral CGRP antagonist approved for the preventive treatment of migraine and the only migraine medication approved as a dual therapy for both acute and preventive treatment.

CGRPs for Migraine Play Role in Value-Based Contracting

Despite a slew of new branded therapies for acute migraine treatment and migraine prevention, many of which target calcitonin gene-related peptide (CGRP) receptors, health plans and PBMs continue to rely mainly on generic triptans for acute migraine treatment and generic beta-blockers, antiepileptics and tricyclic antidepressants for migraine prevention, drug benefits experts say.

Key Findings:

Market Events Drive Changes

In September 2021, the FDA approved AbbVie’s CGRP inhibitor Qulipta (atogepant) for the prevention of episodic migraine. In May 2021, the agency approved Biohaven’s Nurtec ODT (rimegepant 75 mg) for preventive treatment of episodic migraine in adults. It was the first oral CGRP antagonist approved for the preventive treatment of migraine and the only migraine medication approved as a dual therapy for both acute and preventive treatment. In February 2020, the FDA approved H. Lundbeck A/S’s Vyepti (eptinezumab-jjmr) for the preventive treatment of migraine in adults.

Competitive Market Landscape

Payers have equal amount of power and position when it comes to coverage of prophylactic treatments of migraine. More than 90% require patients to fall under certain criteria for coverage eligibility.

Pharmacy, Medical Benefit Implications

Coverage of drugs in this class is under both the pharmacy and medical benefit. Payers cover the medications for migraine prevention with prior authorization. Patients must be 18 or older and have the medication prescribed by a neurologist or a headache specialist. Patients must also have three to four headache days per months and tried other prophylactic options. Finally, in order to get a re-authorization after six months, the prescriber needs to present documentation showing a 50% reduction in headache days since initiation of therapy.

Key Players in Market:

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AIS Health Staff

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