CGRP antibody access and coverage in Canada in April 2020
CGRP antibodies are a new class of migraine preventives. (See this post). These drugs are more expensive than oral preventives. The cost charged to a patient includes the cost of the medication AND the pharmacy fees (variable from one pharmacy to the other).
There are two main categories of medication insurance: public and private.
Private insurers make their own decisions. Some private payers have decided to cover CGRP antibodies, usually with clinical criteria (headache frequency, previous medication failure).
Public insurers (usually linked to provincial Health Ministries) make decisions based on recommendations by an agency called CADTH. The recommendation from CADTH on erenumab is still pending and will most likely set a precedent for other antibodies coming to the Canadian market in the future.
Pharmaceutical companies frequently offer Patient Support Programs (PSP).
These programs usually include financial support, often to offer a bridge until the patient’s insurance takes over reimbursement of the medication. The following text describes the current situation for coverage and Patient Support Programs for CGRP antibodies in Canada, to the best of our knowledge. Be aware that the situation may change rapidly.
General criteria for PSP financial assistance and private plan coverage (may vary from one company to the other):
- 8 days or more of migraine per month
- Two or more previous trials of migraine preventives with failure or intolerance
- Some insurance companies ask for a trial of Botox before trying a CGRP antibody.
The cost is the same ($532 CAD+ pharmacy fees) for the 70 mg and the 140 mg dose.
Patients with private insurance:
- Patients currently receiving free of charge product: Novartis will provide 100% financial support for up to 3 months or until June 15, 2020 to allow your insurance company to make a decision on coverage.
- New patients: until further notice, Novartis will provide 100% financial support for 3 months (3 first doses) to allow your insurance company to make a decision on coverage.
- If either type of patient (new or already enrolled) are denied coverage by their private insurer, Novartis will stop providing free drug after the 3 months free date. HOWEVER, Aimovig GO will continue to provide some financial assistance.
- It’s our understanding that most private insurance plans are covering Aimovig. That being said, within each private payor there are different plans with different drug lists and criteria, and depending on the plan you have you may or may not be covered. For example, some private plans mimic provincial formularies – in this case none of those plans would currently cover Aimovig.
- If you are concerned about losing access to your Aimovig treatment, we encourage you to contact the GO program to discuss your individual circumstances, so that they can help navigate reimbursement, and secure financial assistance.
Patients with public insurance:
- Patients already using Aimovig: Novartis may cover the cost for 3 months (possibly until June).
- New patients: The Aimovig GO program is currently NOT covering the costs for new patients with public insurance.
- The decision of CADTH on Aimovig is not public yet (as of April 13th 2020) but will be released in the coming weeks. Migraine Canada has submitted a patient report that you can read here, based on patient surveys. Migraine Canada is closely watching the file and is prepared to advocate on your behalf to make this medication available for all Canadians.
- INESSS (in Quebec) has issued a report on Aimovig, recognizing the therapeutic value of the drug, but refusing to add it on the list of covered drugs. See the report here (French)
Patients treated with Botox:
- Most insurance companies do not cover the combination of Botox and a CGRP antibody. Therefore, Aimovig may not be covered by the Aimovig GO program if you are treated with Botox. (See this post).
The Aimovig GO program offers information, injection training, reimbursement support and financial assistance for all patients using Aimovig.
To apply for reimbursement of Aimovig before public coverage, your health care provider could fill a special form to get Aimovig covered as an exception drug. This process varies from one province to the other and success is also variable.
The cost of one dose is $623 CAD + pharmacy fee.
Private AND Public insurance patients:
- Until further notice, Eli Lilly will cover the costs of Emgality until a decision is made by the insurance company/public insurer.
- Co-pay may be available if your insurer covers the costs partially.
- Criteria for coverage (LillyPlus program): 8 days or more of migraine and two previous failed preventives (excluding Aimovig, but including Botox and most other preventive medications).
- It is recommended that you speak to the PSP agent about your financial circumstances, once you are enrolled in the program.
- The CADTH review process for Emgality is not yet started.
Patients treated with Botox:
- Since March 6th, Emgality will not be covered for patients who are treated with Botox, as most insurance companies do not authorize the combination of both treatments (see this other post).
- To get access to the LillyPlus program financial support, Botox should be stopped.
More information on private drug plans covering Emgality should be available in the future.
To read more on the Botox/ CGRP MAB combination see here.
Ajovy has been approved by Health Canada as of April 9th 2020. This means that the product should be available to patients over the next few months.
At present time, there is no information available on the Patient Support Program that will be provided by Teva for patients who will use Ajovy.
The CADTH process on Ajovy has been initiated. Migraine Canada is currently working on a patient submission.
Vyepti (eptinezumab, U.S. name)
This medication is now managed by the company Lundbeck. It seems probable that the drug will be submitted to Health Canada, but there is no estimate regarding when it would be available to Canadian patients.
Migraine Canada is dedicated to advocating on your behalf for access to care.
Migraine Canada will be involved as a patient association in the CADTH review process for every medication relevant to people with migraine and headache disorders.
If you have concerns regarding public reimbursement of migraine medications in your province, we encourage you to reach out to your local elected representative or Minister of Health.
If you have concerns about private coverage of medications, we encourage you to talk to your insurance provider and your employer (human resources department).
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THE MIGRAINE TREE
- ACUTE TREATMENTS
- DEVICES AND NEUROMULATIOIN
- PREVENTIVE TREATMENTS
- PROCEDURES AND INJECTIONS
- SELF-CARE AND LIFESTYLE
- SOCIAL LIFE