A Deep Dive into CGRP Utilization Management
THE INTRODUCTION
Migraines are all too familiar for many, with 18% of women and 6% of men in the U.S. experiencing these intense headaches each year. Thought to be a neurovascular pain syndrome, migraines involve complex changes in the brain’s processing. They often start in our teenage years or early adulthood and can fluctuate in severity and frequency over time, generally easing off after the age of 50.
THE SITUATION
For approximately 1 in 7 American adults, migraines are a part of life, with the economic toll reaching an estimated $36 billion back in 2016. And as prescription drug costs keep climbing—by about 4.5% in 2024—it’s more important than ever to ensure medications are used correctly to avoid any unwanted side effects. That’s where CerpassRx steps in. Our utilization management review is all about making sure our policies work, protecting our members, and ensuring medications are used appropriately.
THE SOLUTION
To tackle this, our CerpassRx clinical team took a close look at cases involving atogepant—a drug from the CGRP receptor antagonists family—that were sent to an independent review organization (IRO) for a second-level appeal over the past year. Atogepant stood out because it had the highest number of case submissions compared to other CGRP medications.
These cases went to the IRO mainly for two reasons:
- The need to show that alternative therapies had been tried and either failed, were intolerable, or were contraindicated.
- The concurrent use of similar drug classes, like using both abortive and preventative treatments at the same time.
THE RESULTS
Our findings were clear: every case that went to the IRO for a second-level appeal was upheld, with no reversals.
THE OUTCOME
This outcome reinforces the strength of our policies and our thorough coverage determination process at CerpassRx. We’re committed to ensuring that members have appropriate access to high-cost medications while keeping safety at the forefront. We’ve also added a “white glove” service to our clinical reviews. For CGRP cases, if a neurologist has already approved concurrent CGRP therapy, we respect that decision in future prior authorization requests. This approach not only saves costs but also streamlines the process, aligning perfectly with our mission at CerpassRx to provide top-notch healthcare solutions.
REFERENCES
- Migraine, Pathophysiology of Migraine. Merck Manual Professional Version. July 2024.
- Bonafede M, Sapra S, Shah N, Tepper S, Cappell K, Desai P. Direct and Indirect Healthcare Resource Utilization and Costs Among Migraine Patients in the United States. Headache. 2018 May;58(5):700-714.
- Charles AC, Digre KB, Goadsby PJ, Robbins MS, Hershey A. American Headache Society. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update. Headache. 2024; 64: 333-341.
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ABOUT CERPASSRX
CerpassRx, a leading full-service PBM, is renowned for its tailored solutions addressing diverse client needs. Its distinctive approach encompasses prescription optimization programs, flexible formulary designs, personalized member services, and efficient mail delivery and specialty pharmacy programs. Integrating top-tier pharmacy tools and expertise with premier PBM services, CerpassRx exemplifies excellence. Central to its core values are collaboration, accountability, passion, and empowerment. By prioritizing these principles, CerpassRx empowers clients, fostering an alliance built on trust and mutual success. The company’s mission is clear: to redefine standards and push boundaries, ultimately driving positive change and heightened efficiency in pharmacy benefit management.