Prior authorization requirements for calcitonin gene-related peptide antagonists.

Abstract

To determine whether broad categories of criteria exist among prior authorization (PA) policies from different managed care organizations (MCOs) and to identify similarities and differences among MCO coverage requirements for medications within the calcitonin gene-related peptide (CGRP) antagonist class. Quantitative and qualitative descriptive analysis. PA policies from different MCOs for erenumab, fremanezumab, galcanezumab, and eptinezumab were identified through a comprehensive online search. Individual criteria from each policy were analyzed and grouped into both broad and specific categories. Descriptive statistics were used to identify and summarize trends among policies. A total of 47 MCOs were included in the analysis. The vast majority of policies applied to galcanezumab (n = 45; 96%), erenumab (n = 44; 94%), and fremanezumab (n = 40; 85%), with fewer policies for eptinezumab (n = 11; 23%). There were 5 broad categories of PA criteria found to be included in coverage policies: prescriber specialization (n = 21; 45%), prerequisite drugs (n = 45; 96%), safety considerations (n = 8; 17%), and response to therapy (n = 43; 91%). The final category, titled appropriate use, included any criteria meant to ensure appropriate medication use and included age requirements (n = 26; 55%), suitable diagnosis (n = 34; 72%), exclusion of other diagnoses (n = 17; 36%), and exclusion of concurrent medications (n = 22; 47%). This study identified 5 broad categories of PA criteria used by MCOs in the management of CGRP antagonists. However, within these categories, specific criteria from different MCOs varied significantly.