AMCP Webinar: Market Insights – Future Treatments in and Cluster Headaches

April 2, 2020

From AMCP Nexus 2019 Disclaimer

Organizations may not re-use material presented at this AMCP webinar for commercial purposes without the written consent of the presenter, the person or organization holding copyright to the material (if applicable), and AMCP. Commercial purposes include but are not limited to symposia, educational programs, and other forms of presentation, whether developed or offered by for-profit or not-for-profit entities, and that involve funding from for-profit firms or a registration fee that is other than nominal. In addition, organizations may not widely redistribute or re-use this webinar material without the written consent of the presenter, the person or organization holding copyright to the material (if applicable), and AMCP. This includes large quantity redistribution of the material or storage of the material on electronic systems for other than personal use. How to Ask a Question Welcome Moderator and Presenter Matt Lowe, Vice President, Destin Sampson, PharmD, MBA Business Strategies. Managing Director AMCP VEO Market Access AMCP Market Insights Overview

• Association-led research with AMCP members and non- members at regional and national plans • Blinded format to allow participation and candid feedback • Topics are based upon category, not product, to provide a holistic view of management • Programs are focus group meetings or virtual programs with Clinical Key Opinion leader presentation • Current and future treatment options are addressed to understand clinical and medical management utilization approaches Migraine Market Insights

AMCP Nexus 2019 Moderator and Presenter: Destin Sampson, PharmD, MBA Managing Director VEO Market Access Time Session Title 7:30 AM – 8:00 Breakfast Agenda AM 8:00 AM – 8:45 Welcome & Setting the Stage for the Day AM Migraine Management- Laying the Foundation Acute 8:45 AM – 10:00 Management AM Guest Speaker: Presenter: Jessica Ailani, MD 10:00 AM – Break 10:15 AM Migraine Management – Laying the Foundation 10:15 AM – Preventative Management 12:00 Jessica Ailani M.D. FAHS Presenter: Jessica Ailani, MD 12:00 PM – Lunch • Director, Medstar Georgetown Headache Center 12:30 PM Cluster Headache- Differentiation & Management 12:30 PM – 1:30 • Associate Professor Neurology Approaches PM • Medstar Georgetown University Hospital Presenter: Jessica Ailani, MD 1:30 PM – 2:00 Putting it all together – Group Discussion

2:00 PM – 2:15 Break PM 2:15 PM – 2:45 Workshop 1: PM 2:45 PM – 3:00 Wrap-up and Closing Remarks PM Objectives

• Understand how AMCP members identify and manage members with migraine and cluster headaches • Identify how payers establish coverage criteria for new migraine therapies • Define key information required for payers to aid product differentiation, treatment protocols, and utilization review to ensure optimal outcomes for members • Understand types of RWE needed for use in formulary decision-making and gaps in currently available data • Define the role of non-pharmaceutical treatment options in patient management

8 Methodology • 6-hour live meeting on November 1 at 2019 AMCP NEXUS in National Harbor, MD • Roundtable format, with presentations and group discussion • > 30 million lives covered

Under 500,000 Pharmacy Benefit Manager 15% 31% 500,001-1 million IDN/health system or 340B hospital entity

39% Regional payer 1 million-5 million 15% National health plan 5 million-10 million

Over 10 million

0 National and regional plans as well as broad range of PBMs- national and regional..

9 Meeting Overview

Setting the Stage: Premeeting Survey Results

Clinical Overview: Defining Migraine and Cluster Headaches

Clinical Overview: Laying the Foundation for Episodic Treatments

Migraine Management: Laying the Foundation for Preventive Management

Cluster Headache: Differentiation and Management Approaches Executive Summary Most participants perceived the need to fail more than one to gain access to the CGRP class

Failing one triptan is a reasonable step edit before allowing coverage for a CGRP antagonist to treat cluster headache disease.

True 62.5%

False 37.5%

0% 10% 20% 30% 40% 50% 60% 70% Almost all participants were aware of the lack of response to triptan therapy in patients

About 30–40% of people with migraine do not respond adequately to triptan therapy.

True 87.5%

False 12.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% n=8 Prior to meeting, just over half of participants considered cluster headaches in the migraine category In defining the migraine category for formulary, which types of headache diagnosis are included: (select all that apply)

Acute Migraine 100%

“I think generally they Migraine Prevention all kind of fit together 100% management-wise” – Health Plan Cluster Headache 63%

Other 0%

0% 20% 40% 60% 80% 100% General Meeting Overview Improved education of migraine and cluster headache altered the participants’ perception of the condition and the therapies

Distinct Categories Single Market Basket “They fit together” Episodic Migraine Migraine (acute, preventative, cluster headache) Chronic Migraine

Definitions/Guidelines Cluster Headache Clinical Education Treat the Episode Provider Practices Cure vs Chronic • Treatment is generally considered a cure • Migraine in some patients may be a for the episode chronic disease and treated • Cluster may be a more severe migraine appropriately or severe derivative of migraine • Cluster headache is a separate condition with severe episodes

“[migraine is chronic,] I think I already knew that, but I don’t think I’ve ever heard that” - Health Plan Recently Approved CGRPs & Novel Mechanism Acute / Cluster Prevention Oral SQ IV Episodic Headache X X (Aimovig) galcanezumag X X X (Emgality) X X (Ajovy) Recently approved since AMCP Market Insights Meeting X X X (Vyepti) X X (Reyvow) X X Nurtec ODT Episodic and Chronic Migraine Definitions for Episodic Migraine and Treatment Recommendations Migraine Recommendations

Without Aura: With Aura: Level A: Level B: At least five attacks At least 2 attacks All Anti-emetics: Attacks last 4-72 hours untreated 1 or more of the following fully reversible IV Metoclopramide & At least 2 of the following 4 characteristics aura symptoms DHE Nasal Spray Prochlorperazine • Unilateral location • Visual, sensory, speech/language, NSAIDs: Anti-dopamine: • Pulsating quality motor, brainstem, retinal Diclofenac, aspirin, naproxen, IV Chlorpromazine & Droperidol IV • Moderate or severe pain intensity At least 2 of the following 4 characteristics: ibuprofen • Aggravation by or causing avoidance of • At least one aura symptom spreads Ergots: IM/IV DHE routine physical activity gradually over 5 minutes, and/or two or Acetaminophen Acetaminophen/aspirin/caffeine NSAIDS: Ketorolac During headache at least 1 of the following more symptoms occur in succession 500/500/130 mg • Nausea and/or vomiting • Each individual aura symptom lasts 5- Acetaminophen 1000 mg (for non- Opioids: Codeine/acetaminophen, • Photophobia and phonophobia 60 minutes incapacitating attacks) Tramadol/acetaminophen • At least one aura symptom is unilateral • Aura is accompanied, or followed within Butorphanol nasal spray 60 minutes, by headache Transient ischemic attack has been excluded Marmura MJ. Headache 2015 Treatment of a migraine attack is managed primarily by the PCP who may not have the appropriate expertise

Clinical Insights into Patient Experience and Prognosis Patients struggle to receive appropriate treatment “You’re looking to wait six months to get treatment… primary care • PCPs will often recommend multiple therapies (OTC, herbals, opioids) over the treats the vast majority of course of months and even years before obtaining appropriate therapy migraine ” - Health Plan Contraindications and adverse effects prevent patients from receiving adequate therapy • Many therapies are associated with adverse effects: cardiovascular, gastrointestinal, “Patients who failed a triptan or sedation don’t refill it are getting opioids • Contraindications include pregnancy and breastfeeding and barbiturates” – Headache Specialist Poorly treated patients are increased risk for transitioning to chronic migraine

• Non-adherence to “We don’t get diagnosis codes on • Overuse of medication, caffeine opioids [to manage them in • Increased headache frequency migraine]” • Frequently, receive opioids or barbiturates (~40%) -PBM Nerivio (recently approved disposable device) for Acute Treatment and Cluster Is Favorable Among Participants

Participants agreed the clinical data is sufficient to be considered in their review of therapies for acute migraine • Health plans recommend registering with MediSpan and First Data to enable the placement on the pharmacy benefit and proper adjudication • Allowing PBMs to manage the distribution and adjudication would be preferable for most plans • Positioning the product for placement on the medical benefit would not be covered Participants suggested the following evidence or endpoints which would assist in the renewals/reauthorizations of the product: • Reduction in ER visits • Medication-sparing (triptans, opioids) • Decrease in office visits • PROs – practical and clinically in use • Use in pregnancy • Decrease in exacerbations / attacks • Reduction in medication overuse Participants recognized the positioning of a device as a good option especially for those patients who may be intolerant, contraindicated or at risk for rebound migraine • Validation of a patient ability to use the device effectively would be required by payers • Communications should tell the story of the value of the product in a direct and succinct manner • Burden and risk of patients with migraine • Clinical evidence of the device The expected price range • Potential cost implication of patients using the device • Training and patient support to ensure appropriate utilization (hub services, provider certifications and for such a device would be patient training) between $300 to $500 Novel Agents for Acute Migraine: Ditans and Gepants

REYVOW (lasmiditan) NURTEC ODT (rimegepant) UBRELVY () (Eli Lilly/CoLucid) (Biohaven) (Allergan)

Class Ditan Gepant Gepant

Indication Acute Acute Acute

Small Molecule Small Molecule Mechanism 5-HT Receptor Agonist* 1F CGRP Receptor Antagonist CGRP Receptor Antagonist

Formulation Oral Tablet Orally Disintegrating Tablet Oral Tablet

2-Hour Pain Free Vs SPARTAN - Phase 3 301 - Phase 3 Achieve I - Phase 3 Placebo SAMUARI - Phase 3 302 - Phase 3 Achieve II - Phase 3

Study 1 38.6% vs 21.3% 19.2% vs 14.2% 21.2% vs 11.8%

Study 2 32.2% vs 15.3% 19.6% vs 12.0% 21.8% vs 14.3%

*Launched since date of meeting Payers will likely wait for all newer agents to be approved then review the entire class

Ditans Gepants- pipeline Payers would likely block (lasmiditan) (rimegepant, ubrogepant) the new agents

• Because it targets 5-HT1F it is not • New oral options that targets CGRP a • Wait to review all four of the agents considered a vasoconstrictor with migraine attack (acute setting) together, ~6 months similar efficacy to triptans • Studied in patients who failed triptan; • Medicare coverage to be • Dizziness was seen in about 18 triptan-naïve and concomitant use of determined percent of patients in the clinical triptan • May be rolled out under PA trials • Not anticipated to cause medication • Likely to receive a driving restriction overuse headache in the label Formulary exception/appeal may allow • Operate peripherally, not access – payers will assess demand • Expectations to receive controlled vasoconstrictive based on submitted appeals substance classification, awaiting DEA • Side effect profile is promising – no sedation and minor nausea Participants expressed it will likely step through 2 triptans Participants were confused with the perceived low proportion of patients “If we are getting all these appeals… who achieved a response – overturning denials… So we will take it “The difference between a C4 and C5 is recommend messaging describing back and look at it again. ” huge… its going to restrict access” differences between 2-hour Pain Free — IDN — Health Plan and 2-hour Pain-Relief endpoints Opportunities for Potential Positioning of the Novel Agents

Segment plans, PBMs and IDNs which separate management of Acute 1 Migraine, Migraine Prevention and Cluster Headache

Identify and quantify patients who are: Payer Unmet • Cardiovascular risk (contraindicated) 2 • Unable to tolerate the sedative effects of triptans Need in • At risk for medication overuse migraine Managing Potential outcomes of interest with payers: Acute Migraine • Decrease in ER visits 3 • Hospitalizations • Outpatient visits • Medication sparing (opioids; triptans)

Engage in a campaign to educate PCPs on the treatment of migraine and 4 the specific needs of patients who might not be candidates for triptans Definitions of Chronic Migraine and Treatment Options Chronic Migraine Migraine Preventive Treatments Level B: Level C: Level U: Level A Probably Possibly Inadequate or Ineffective 8 days/month with Effective High volume of effective effective conflicting attacks (more than 15 migraine symptoms or AEDs SNRI/TCA ACE CA inhibitor NOT effective days/month) for more headache relieved by Divalproex Lisinopril Acetazolamide Lamotrigine triptan Venlafaxine Anticoagulants than 3 months α-agonists Coumadin Probably NOT B-blockers Picotamide effective B-blockers Atenolol Guanfacine SSRI /SSNR1 Clomipramine Metoprolol Nadolol Fluvoxamine AEDs Fluoxetine Possibly NOT ARB A minimum of 5 Less likely to be Candesartan AEDs effective attacks meet criteria employed; more likely *CGRP MAB Gabapentin Clonazepam Erenumab aooe B-blockers TCAs for migraine with or to overuse, and more Fremanezumab Nebivolol Protriptyline without aura refractory to vfrm Pindolol B-blockers treatment (2-3 acute Bisoprolol gnlm Leukotriene Ca++ Blockers options) Antag Nicardipine Cyproheptadine Nifedipine ICHD 3 Cephalalgia 2018; 38:1-21 Nimodipine Marmura MJ. Headache 2015 Silberstein SD. Neurology 2012 The expansion of the prevention category offers challenges and opportunities for plans, providers and manufacturers

• The CGRPs are projected a 3-fold increase in sales by • Plans will likely aim to restrict access 2020 (Burke et al. 2019) The influx of new agents to newer agents to drive rebate targeted to migraine • 4 new agents expected for approval by Q2 2020 • Lack of perceived clinical differentiation will fuel contract revenue negotiations with multiple options • Plans and providers will seek education on the diagnosis and treatment of chronic migraine Low awareness of the Plans question the competency of a typical family practice • diagnosis of conditions physician or their mid level providers to differentiate Innovative plans will separate the between acute and chronic migraine acute from prevention – but others will struggle • Introduction of new agents attracts an influx of patients • Plans will respond to provider hoping to find an agent that works for them requests for denials to maintain • Number of neurologists is decreasing every year Volume of patients and scarce provider satisfaction credentialed providers • 500 headache specialists to treat 40 million patients • Plans need assistance identifying the • Several plans may not have access to specialists appropriate patient within their • Many health plans do not have the ability to stratify populations Patient economic burden is patients within the migraine category (acute, prevention, • Opportunities to quantify the patient undefined and unrecognized cluster) burden include medication-sparing • Few studies to effectively represent the economic burden in the data (triptan, opioid) relieved by effective prevention of migraine Only the CGRPs are uniquely indicated to prevent migraine – but payers will likely continue to favor generic options

Over 40 drug therapies used to prevent migraine

• Variable rates of response • Rarely curative 2 neurostimulation devices FDA • Can have adverse effects cleared for migraine prevention • Supraorbital transcutaneous nerve stimulator, Single pulse Only 8 agents FDA approved for transmagnetic stimulator prevention of migraine

• Propranolol, “We want to make sure they tried a • Timolol, preventative treatment, not just a • Dilvalproex sodium, triptan, [prior to a CGRP]” • Topiramate, - PBM • Onabotulinum toxin A • Erenumab-aooe, Unique • Fremanezumab-vfrm, Headache • Galcanezumab-gnlm, Indications Lipton Headache 2015 The pipeline activity of the CGRP class will likely draw increased attention and scrutiny of migraine Indications Administration The introduction and expansion of CGRPs Acute / Cluster Preventation Oral SQ IV Episodic Headache is driving greater awareness of migraine • Current awareness of the differentiating factors three Erenumab X X indications (acute, preventative, and cluster headache) (Aimovig) remains low

Galcanezumab • Payers will likely favor agents on the pharmacy benefit X X X (Emgality) (SC and oral) • IV products would likely need differentiating clinical Fremanezumab X X evidence to gain coverage (Ajovy)

Investigational Agents

Eptinezumab x x x

Gepants x x (category) Payers’ limited familiarity with migraine and cluster opens potential study opportunities to improve CGRP positioning

Participants expressed the need for greater Some payers may seek other measures beyond understanding on: clinical trials for differentiation: Burden: • Burden of the adverse effects: • Overuse of medication: patients who receive contraindicated therapy (CV, gastrointestinal events, • Sedation pregnancy, other) • Driving impairment • Switching practices, (frequency, outcomes) • Medication overuse headaches • Non-adherence to medication (triptans, topiramate, • Non-adherence to medication (triptans, topiramate, divalproex, beta-blockers, antidepressants) due to divalproex, beta-blockers, antidepressants adverse events Reduction in economic outcomes: ER visits, • Patient characteristics contraindicated for triptans outpatient visits, hospitalizations • History of , stroke, or transient Reduction in medication overuse or misuse: triptans, ischemic attack opioids • Peripheral vascular disease Patient Reported Outcomes: practiced or performed • Uncontrolled hypertension in the clinic • Ischemic bowel disease • Pregnancy …I like adjusted quality-of-life here and PROs and patient satisfaction surveys because [of the significant] indirect costs” –Health Plan CGRP product exclusions from formulary may indicate unrecognized clinical differentiation, limited indications and perhaps a unique MOA

Payers generally perceive the CGRPs to be clinically equivalent

…we’ve looked at them all and found them Drivers of formulary exclusions with CGRPs to be clinically equivalent. So you don’t need them all… throw them over to trade • Undifferentiated clinical evidence and lack of real-world data and they do their thing.” • Contracting based on one-of-two scenarios – net cost goal –IDN

Influence of Indications on Contracting Negotiations • In the absence of differentiation, more indications (acute, preventive and/or cluster headache) would likely have prove an advantage

“Emgality… may have a little • Fulfills goal of a stable formulary over a longer time period bit of leg up [with the cluster headache indication]” – PBM Value of a Different MOA • Several participants indicated decisions to restrict CGRPs include the decision to have a CGRP receptor and a ligand antagonist Cluster Headache Cluster Headache

MOST COMMON LONGEST LOWEST ATTACK 0.02%-0.1% OF FIRST ATTACK CAN KNOWN AS TRIGEMINAL DURATION ATTACK FREQUENCY POPULATION; OCCUR ANY AGE, “SUICIDE” AUTONOMIC TAC (15-180MIN) (1 QOD TO 8X DAY) MORE COMMON AVERAGE AGE HEADACHE CEPHALALGIA IN MEN IS 31.5 Definitions for Cluster Headache

At least 2 cluster periods lasting from 7 Either or both of the following days to 1 year (untreated) • A sense of restlessness or agitation • For episodic separated by pain free periods lasting at • At least one of the following symptoms or signs, least 3 months (for episodic), or less than 3 months ipsilateral to the headache (for chronic) – conjunctival injection and/or lacrimation At least 5 attacks fulfilling below – nasal congestion and/or rhinorrhea • Severe or VERY severe unilateral orbital/supraorbital – eyelid edema and/or temporal pain, lasting 15min-180 min if – Forehead and facial sweating untreated • 1 attack every other day up to 8 attacks per day – Miosis and/or ptosis

Episodic cluster headache is more common than chronic Cluster headaches are difficult to treat and clinically manage Cluster Attack Cluster Cycle or Period Most often same 90% have at time of day (later Seasonal least 1-month afternoon/after Variation remission dinner or middle between cycles of the night

During cycle ~10% don’t have patients speak Lasts 2-12 remission weeks of self-harming (chronic cluster) behavior

About 75% of patients are misdiagnosed, often not receiving accurate diagnosis for a decade AHS Guideline Recommended Treatment for Cluster Headaches

Acute/Episodic Cluster Headache Cluster Headache Prevention Level A: Level B: Level A: Oxygen via loose face mask, oral Greater Occipital Nerve Block 7-10 Liters, over 20-30 minutes Anti-dopamine: IV Chlorpromazine & Droperidol IV Level B • nasal spray Ergots: IM/IV DHE Civamide nasal spray • injection NSAIDS: Ketorolac (not available in the US) Zolmitriptan nasal Opioids: Codeine/acetaminophen, Tramadol/acetaminophen Level C

Level C Lithium Verapamil Octreotide SQ (not used in US) Warfarin Melatonin Level U : DHE Spray

Treatment Additions Since Guideline Publications

EMGALITY (galcanezumab) gammaCore • Only FDA approved for Episodic Cluster headache • Vagal nerve stimulator • 300 mg once monthly during cycle • Patients applies unilaterally attack for 2 minutes • Pre-filled syringe • Maximum 24 stimulations/day • May be stopped between cluster cycles • Cleared for acute treatment and prevention of migraine Payers may recognize the clinical distinction between cluster headaches and migraine, but struggle to separate management

“[Cluster and Small population and heavy patient Payer Insights migraine] just get burden • Payers need significant education in lumped into the • Very small population (0.02%-0.1%) same category. I “In about 30% of patient type, provider diagnosis, clinical would have no way patients with cluster • Patients not functional with severe pain symptoms and burden of disease of pulling out headache, it takes • Best treatment with specialist, not the ER [cluster]” them a decade to • Management of cluster separate from - Health Plan actually get the Accurate diagnosis migraine is challenging diagnosis” • Underdiagnosed – patients struggle to get – Headache • Specialist access is a major problem for “I think this access appropriate diagnosis Specialist payers; a consult is necessary but fails [to the appropriate • Overdiagnoses – PCPs/neurologist lack to guarantee an accurate diagnosis provider] is experience probably the • Excess scans and labs lead to increased costs • CGRP is likely a first line options for single biggest and delay appropriate treatment accurate diagnosis of cluster issue that I think headaches we're facing in kind of looking in Specialist scarcity some of these • Patients may wait 6 months for appointment therapies and • Neurologist prescriber often required but may some of these not have expertise disease states. ” “You can have your [CGRP] first-line – Health Plan • Headache specialist scarce (~500 in US) “We require prescriber [in cluster]” specialty” - Health Plan – IDN Key takeaways

• Limited number of providers who specialize in headache treatment may impact access for patients – plans with PA requirining specialists may impact ability of patients to receive treatment • Availability of novel agents are changing the way migraines are treated • Episodic • Chronic • Non-pharmacologic • Low awareness of differentiation of migraine (episodic and chronic) and cluster headaches • Opportunity for additional clinical education as additional treatment options become available for AMCP members to understand and manage this category Look for the summary report in April issue of JMCP

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