OBJECTIVES:

To examine trends and variations in Medicare Advantage (MA) prior authorization (PA) policies across insurers, years, and selected high-cost infusion immunotherapies and biosimilars, including rituximab, pembrolizumab, nivolumab, trastuzumab, and bortezomib.

METHODS:

We collected publicly available PA policies for MA insurers operating in Colorado from 2017 to 2022. For each of the selected immunotherapies, we determined the insurer, the plan name and type (HMO or PPO), the year of coverage, whether the product is subject to PA, and whether there are any restrictions that determine the product’s coverage.

RESULTS:

All of the products were subject to PA by at least one insurer during at least one year of the study period. Additionally, the number of plans requiring PA for biologics with no biosimilars (.i.e., bortezomib, nivolumab, and pembrolizumab) increased significantly from 8% in 2020 to 65% in 2022. Among biosimilars, we found variation in PA requirements between the different insurers and plans. As of 2022, 40% of the plans required PA for the original and more costly biologics (i.e., rituximab and trastuzumab) instead of their biosimilars, compared to only 8% in 2020. For products that were recently approved by the FDA, insurers typically have a two-year lag before requiring PA. Finally, some insurers restrict coverage through different PA mechanisms such as requiring step therapy through the company’s preferred drug or approving a limited 30 days’ supply.

CONCLUSIONS:

Further investigation on the increasing use of PA by insurers is needed to fully understand the impact of these trends on patients’ access to care and cancer related outcomes.