ICER to payers: Go easy on CGRP restrictions if pricing stays reasonable

Money
Lead PBM Express Scripts has a prior authorization system in place for Aimovig that it says will “help payers get the most value for the money they spend.” (Pixabay)

The Institute for Clinical and Economic Review isn’t taking a new group of migraine drugmakers to task over high costs, thanks to pricing decisions it’s called “responsible.” But it does have some suggestions for payers about how to manage the drugs.

The cost watchdog has already recommended that patients use Amgen and Novartis’ Aimovig and Teva’s still-in-development fremanezumab, both members of the brand-new CGRP class, only after they’ve exhausted other therapies. But payers requiring that patients try other drugs first shouldn’t make them jump through hoops to prove they’ve done so, ICER said in its final report on the class.

RELATED: Thanks to lower-than-expected price, ICER backs Amgen's Aimovig—but only after other drugs fail

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Prior authorization systems should feature criteria that are “relatively streamlined and allow documentation of eligibility through a clinician statement” saying that patients have tried two or three other treatments to no avail, the body said, dismissing the idea that payers should require “extensive submission of clinical documents.”

Of course, that advice only applies for drugmakers that have established “reasonable pricing,” as ICER says Aimovig’s makers have. Amgen rolled out the product with a $6,900 list price, below the $8,000 to $10,000 range industry watchers expected—and its forthcoming competitors, including Teva, Eli Lilly, Allergan and Alder, should follow suit, in ICER’s view.

“Manufacturers should continue to exercise restraint and ensure net prices align reasonably with the added benefits for patients. Consideration of price increases in future years should be transparently justified by new clinical evidence of superior performance,” it said.

That said, ICER still thinks payers should go after additional discounts through negotiations and pressure drugmakers to drop their prices by using formulary management tactics, it said. If they decide to give a single CGRP med a preferential formulary spot, though, they should “maintain options for clinicians and patients to seek coverage for more than one CGRP inhibitor,” it said.

With a wide-open market ready and waiting for new migraine therapies, lead PBM Express Scripts has already flexed its muscles, establishing a prior authorization system it has said will “help payers get the most value for the money they spend.” Public pricing warnings from payers likely also factored into Amgen’s decision to price Aimovig below expectations.

"We value ICER’s continued efforts to ensure payers get the most value for their spend on prescription drugs, which is a goal that Express Scripts and ICER share," an Express Scripts spokeswoman said in an emailed statement.

RELATED: Amgen, Novartis 'overwhelmed' by early interest in migraine med Aimovig: expert

So far, though, because Amgen has been doling out Aimovig for free, the “impact of potential payer hurdles to getting on therapy,” is unclear, Credit Suisse analyst Vamil Divan wrote to clients earlier this week.

The demand for the product is “clearly” there, though, he added, after talking with Yale University migraine specialist Dr. Christopher Gottschalk. “Our expert talked about the companies being ‘overwhelmed’ in trying to keep up with the initial interest,” Divan wrote.

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