Chimeric Antigen Receptor (CAR) T-Cell Therapy | Access & Reimbursement | US | 2024

CAR T-cell therapies, such as Gilead / Kite Pharma’s Yescarta and Johnson & Johnson Innovative Medicine’s Carvykti, have given hope to patients with relapsed/refractory (R/R) non-Hodgkin’s lymphoma (NHL) and patients with R/R multiple myeloma. Priced at more than $400,000 per infusion, these therapies also come with unique administrative and budgetary challenges for MCOs and providers. As the market for these novel therapies gains ground, we explore how MCO PDs/MDs approach reimbursement of these expensive therapies for NHL and multiple myeloma and how coverage decisions in their largest commercial and Medicare Advantage plans impact prescribing by surveyed hematologist-oncologists.

Questions answered

• What factors drive physicians’ choice of a CAR T-cell therapy, both in the second and later lines of therapy? How concerned are oncologists about the latest FDA safety warnings on such therapies?
• How are CAR T-cell therapies and other targeted therapies covered under commercial and Medicare plans, and what kind of contracts and payment schemes do MCOs commonly use to address these therapies’ high cost?
• What prior authorization requirements and other utilization management controls do payers apply to CAR T-cell therapies, and how do these restrictions affect hematologist-oncologists’ prescribing?
• How have various policies, including easing reimbursement of CAR T-cell therapy delivered in the outpatient setting, affected treatment behavior? How is access to CAR T-cell therapies affected by off-the-shelf bispecific antibodies, such as Roche’s Lunsumio for R/R NHL and Johnson & Johnson Innovative Medicine’s Tecvayli for R/R multiple myeloma? Do MCOs encourage patients to use these therapies before a CAR T-cell therapy?

Content highlights

Geography: United States

Primary research: Survey of 101 U.S. hematologist-oncologists; survey of 40 U.S. MCO PDs / MDs

Key drugs covered: Breyanzi, Kymriah, Tecartus, Yescarta, Abecma, Carvykti

Key analysis provided:

• Reimbursement and contracting
• Access and prescribing
• Opportunities and challenges for emerging and recently approved therapies

Product description

U.S. Access & Reimbursement provides integrated brand- and disease-level insight on reimbursement dynamics and the impact of U.S. payer policy on physician prescribing behavior in the market access environment, including up-to-date analysis of drug coverage and restriction policies and payer and prescriber perspectives on key marketed drugs and receptivity to emerging therapies.