Presentation (CTI)

OBJECTIVES: Historically, US commercial health plans have rarely restricted access to oncology treatments. However, recent research suggests a growing use of utilization management (UM) for these treatments. Our objective was to examine changes in commercial health plan oncology coverage from 2017-2024 and variation in coverage based on drug characteristics and across health plans.
METHODS: We analyzed coverage data from the Tufts Medical Center Specialty Drug Evidence and Coverage (SPEC) Database, which tracks coverage decisions issued by 18 large US commercial health plans. Coverage decisions were benchmarked against FDA-approved indications and categorized by UM criteria, specifically patient subgroup restrictions, step therapy protocols, prescriber requirements, and ‘other’ restrictions. Using data from August 2024, we examined variation in UM use across drug characteristics and health plans and we assessed changes in use of UM over time (2017 to 2024).
RESULTS: As of August 2024, SPEC included 5,419 oncology coverage decisions for 363 drug-indication pairs (e.g. abemaciclib for metastatic breast cancer). UM was applied in 35.2% of oncology decisions, compared to 73.2% non-oncology decisions. Use of UM criteria varied by drug characteristics, with biologics and cell/gene therapies more likely to include UM, as well as drugs with biosimilar or generic alternatives. In contrast, treatments for orphan cancers were less likely to include UM. Plans varied substantially in their use of UM. Between 2017 and 2024, UM use for oncology drugs doubled from 18% to 36%, driven largely by increases in step therapy protocols and prescriber requirements.
CONCLUSIONS: While UM criteria remain less common for oncology treatments compared to non-oncology drugs, their use has increased substantially over time, particularly in the form of step therapy protocols and prescriber requirements. Variation in UM by drug characteristics and across plans contributes to unequal patient access.