As the prevalence of chronic pain associated with numerous indications (e.g., osteoarthritis, cancer) and of idiopathic origin (e.g., chronic back pain) continues to increase in the United States, obtaining favorable market access and reimbursement for branded analgesics will become increasingly challenging. The current analgesic market contains a wide variety of well-entrenched and established therapeutic options across several drug classes, frequently available in generic forms, and continues to see entry of new analgesics that are most often either abuse-deterrent formulations of existing opioid analgesics or reformulations of existing products. Despite the quantity of analgesic options available, surveyed payers and physicians are united in their acknowledgement of the continuing clinical shortcomings of many therapies and in their support for new analgesics. Emerging analgesics that are able to differentiate from current products on clinical factors and are able to present persuasive pharmacoeconomic data will be most likely to obtain favorable market access/reimbursement conditions from MCOs, which will then facilitate use among prescribers who are particularly sensitive to the impact of cost-sharing on their chronic pain patients.

Questions Answered:

  • In light of the expanding genericization of current analgesics, branded agents are frequently subject to reimbursement restrictions and utilization controls. What reimbursement restrictions and utilization controls are the most commonly used for key analgesics? How restrictive do prescribers perceive these controls to be? How do utilization controls impact prescribing and treatment selection? 
  • Abuse/misuse of opioid analgesics are a prominent concern to both payers and physicians. How does the availability of ADFs of opioid analgesics impact physicians’ prescribing? How do ADFs of opioid analgesics currently fare in market access given the variety of branded and generic opioid analgesics without abuse-deterrence?
  • Despite the crowded analgesic market for the treatment of chronic pain, emerging analgesics such as those from Depomed/Grünenthal (cebranopadol) and Pfizer/Eli Lilly (tanezumab) are likely to receive formulary coverage in most MCOs. What reimbursement restrictions and utilization controls are these agents most likely to incur? What actions can drug developers undertake to lessen the impact of these controls on prescribers? How will various degrees of control impact physician willingness to prescribe these agents?

Scope:

Markets covered: United States.

Methodology: Surveys of 143 PCPs and pain specialists and 30 managed care company officials, including 15 pharmacy directors and 15 medical directors, in January 2017.

Indication coverage: Chronic pain.

Key drugs covered: Celebrex, Cymbalta, Hysingla ER, Lyrica, Nucynta ER, OxyContin, Targiniq ER, Zohydro ER, cebranopadol, tanezumab.

Key companies mentioned: Acorda, Depomed, Eli Lilly, Endo, Grünenthal, Horizon, Janssen, NeurogesX, Pernix, Pfizer, Purdue, Zogenix.

Table of contents

  • Chronic Pain - Access & Reimbursement - Detailed, Expanded Analysis (US)

Author(s): Joyce Spadafora, ALM

Joyce is a business insights analyst in Decision Resources Group’s central nervous systems and ophthalmology division, where she provides expert insight into commercial aspects of drug development and market sizing across psychiatric and pain indications. She has worked extensively in DRG’s schizophrenia and chronic pain content.

Prior to joining DRG, Joyce spent several years in the biotech industry focused in research and development and in biotech consulting. Her project experience covered indications including psychiatry, pain, infectious diseases, respiratory, and ophthalmology. Beyond my therapeutic and industry knowledge, she holds a Masters in Extension Studies in Psychology from Harvard University and a B.S in Mechanical Engineering with Biology from the Massachusetts Institute of Technology.


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