February 1, 2019 / 3:37 PM / 8 months ago

REFILE-EXCLUSIVE-Optum to cover Amgen, Eli Lilly migraine drugs, exclude Teva

(Corrects name of UnitedHealth Group in first paragraph)

By Caroline Humer

NEW YORK, Feb 1 (Reuters) - Optum, a top U.S. pharmacy benefit manager owned by UnitedHealth Group Inc, has included new migraine drugs from Amgen Inc and Eli Lilly and Co as preferred treatments on its lists of covered drugs, according to an Optum client note viewed by Reuters.

Teva Pharmaceutical Industries Ltd’s rival product is excluded on one list and patients can pay more for it some cases on a second list, the note said.

Like at rivals Express Scripts and CVS Health Corp, Optum’s lists of covered drugs, or formularies, cover tens of millions of consumers who receive their healthcare from employers and health insurers.

About 39 million Americans suffer from migraine headaches, according to the Migraine Research Foundation, and global migraine drug sales could reach $8.7 billion by 2026, according to analytics firm GlobalData.

Optum’s decision secures easier access to customers for Lilly at all three of the biggest pharmacy benefit managers (PBMs) - including CVS and Express Scripts - and gives Amgen a leg up after CVS decided not to include it as a preferred drug.

Teva only has preferred status at CVS while Amgen has it at Express Scripts, part of Cigna Corp.

Inclusion on a preferred drugs list by the largest PBMs and health insurers is critically important for sales of new medicines. Increasingly, PBMs are choosing a subset of treatments for their coverage list when there are multiple treatments that are considered equivalent.

The treatments, approved by the U.S. Food and Drug Administration last year, belong to a class of drugs called CGRP inhibitors that have proven effective in helping to prevent migraines.

A Teva spokeswoman said that the company is committed to increasing access to Ajovy regardless of formulary decisions and is still offering discounts that allow patients to pay nothing in some cases, regardless of insurance.

“Since Ajovy injection launched in September, we have experienced strong demand and steady growth, and we continue discussions with payers,” the spokeswoman said.

An Amgen spokesperson said that the company was pleased with the decision and is committed to ensuring affordable access to the drug. Amgen and Novartis AG share U.S. revenue from the CGRP treatment.

Lilly did not have an immediate comment.

Optum’s premium formulary, a list of covered drugs that excludes coverage of some brand names, will include Amgen’s Aimovig and Lilly’s Emgality and exclude Teva’s Ajovy, effective Feb. 1, according to the client note.

Its select formulary does not exclude Ajovy, but relegates it to a lower access level that would typically require a higher out-of-pocket cost, it said.

PBMs typically extract discounts from drugmakers in return for favorable placement on their list of covered drugs, such as through a low co-payment, or coinsurance payment, for their members.

All three migraine drugs have a list price of $575 a month, or $6,900 a year. The prices do not reflect rebates and discounts that drugmakers typically provide to PBMs, who design and negotiate benefits for employers and insurers.

All three drugmakers have said they are providing a limited duration supply of the drugs at no cost directly to patients in addition to other assistance programs.

Amgen was the first of the three companies to launch a drug in the new class. The rival drugs from Teva and Lilly, which work in a similar manner, came on the market soon after.

The three PBMs together cover the majority of the more than 150 million Americans who receive benefits through their employers.

Their clients, including insurers and corporations, may choose not to follow a PBM’s recommendations on coverage, but typically pay more to do so. (Reporting by Caroline Humer; Editing by Jeffrey Benkoe)

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