The Majority of Surveyed PCPs and Pain Specialists Indicate That They Have Experienced Reimbursement Restrictions When Prescribing Janssen's Nucynta ER for Chronic Low Back Pain
Decision Resources
Decision Resources, one of the world’s leading research and advisory firms for pharmaceutical and healthcare issues, finds that the majority of surveyed primary care physicians (PCPs) and pain specialists indicate that they have experienced reimbursement restrictions when prescribing Janssen's Nucynta ER for chronic low back pain. Prior authorization and formulary exclusion are the most frequently reported restrictions encountered. Sixty percent of surveyed managed care organizations’ (MCOs) pharmacy directors report Nucynta ER is listed as a pharmacy benefit on their largest commercial plans, compared with 88 percent of respondents indicating Purdue’s OxyContin is listed as a pharmacy benefit. In contrast, only 44 percent of MCO pharmacy directors indicate that AstraZeneca/Pozen’s fixed-dose combination Vimovo is listed as a pharmacy benefit, likely due to the multitude of generic equivalents available.
The new U.S. Physician & Payer Forum report entitled also finds that some surveyed MCO pharmacy directors expect the coverage and formulary tier status of Nucynta ER to improve in their largest risk-based commercial plan in one year’s time. Twenty-eight percent and 36 percent of surveyed MCOs report that Nucynta ER is currently covered on tier 2 or tier 3 of their formularies, respectively, while 32 percent and 44 percent expect the drug to be included on either tier 2 or tier 3 in one year’s time.
The report also finds that the cost of Pfizer’s tanezumab may potentially be a major hurdle to prescribing for both PCPs and pain specialists. Eighty-three percent of surveyed PCPs and 73 percent of pain specialists responded that the high price of the anti-NGF biologic analgesic tanezumab for their patients would dissuade them from prescribing the drug in chronic low back pain—we expect that as a biologic agent, tanezumab would be priced at $35 per treatment day or higher.
“Just over one-third of surveyed MCO pharmacy directors do not expect tanezumab to be reimbursed. If tanezumab is approved by the FDA, surveyed pharmacy directors believe that the anti-NGF therapy would more likely be reimbursed on commercial formularies (60 percent) than on Medicare PDP formularies (44 percent), although there is some risk of the drug not being reimbursed at all,” said Decision Resources Analyst Natalie Taylor, Ph.D. “All surveyed pharmacy directors who believe tanezumab would be reimbursed expect cost controls to be applied to its coverage, with the requirement for prior authorization being the most likely cost control facing tanezumab.”
Also, nearly two-thirds of surveyed pharmacy directors indicated that they are likely to implement a bundled payment system for tanezumab, which could financially incentivize physicians to choose a less-expensive treatment option instead.
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