In 2018, the FDA approved 3 new, injectable drugs developed to fight migraine headaches. Expensive new drugs are the talk of the industry, with many more making their way through the pipeline. To serve both the plan and the member, clients need experienced clinicians at their side to manage plan exposure while covering appropriate treatment options.
“Our New to Market clinical program supports evidence-based decisions for the plan and its members,” explains Valerie Woerndle, Director of Clinical Operations. As a new drug comes to market, we:
- Add the drug to our New to Market review list.
- Flag the drug for prior authorization (PA) clinical review.
- Develop appropriate clinical criteria around use of the drug.
- Determine where the drug will sit on the formulary.
This process sparked the launch of our Migraine Management Program. “Our study showed the annual cost for migraine treatment with existing drugs was approximately $150 a year,” says Valerie, “while the annual cost of the new medications would be about $6,800.” The team developed clinical criteria around how the new medications should be used. When they started reviewing patient requests for treatment, they found that 75% of the time, patients do not meet the criteria.
“It makes sense to start the patient with a clinically effective, lower-cost drug, which may work quite well,” Valerie says. “Advice from a trained clinical pharmacist vs. a free reign approach can mean substantial savings for the plan, while still taking good care of members.”
“Prior authorization ensures physicians use evidence-based rules and prescribe the most cost-effective medication,” says Valerie. “A lower approval rate is more effective and our 60% PA approval rate is among the best in the industry.” She adds that CastiaRx takes great care to evaluate each PA thoroughly and in a timely manner with an average turnaround time of 36 hours.