Non-Hodgkin’s lymphoma (NHL) encompasses a plethora of subtypes with varying prognoses, and the treatment landscape is entrenched with targeted agents. Roche’s Rituxan, Janssen / AbbVie’s Imbruvica, and AbbVie / Roche’s Venclexta are cornerstones of treatment, and the approval of CAR T-cell therapies has transformed the treatment armamentarium for diffuse large B-cell lymphoma (DLBCL). The cost of NHL treatment is set to increase with the expected approvals of emerging therapies such as Roche’s glofitamab and ADC Therapeutics’ loncastuximab tesirine(Zynlonta). To control rising costs, payers have a toolbox of utilization management (UM) strategies at their disposal. This report analyzes the reimbursement environment for the major therapies for NHL and chronic lymphocytic leukemia (CLL) in MCOs’ largest fully insured commercial and Medicare plans. In addition, we examine how MCO formulary decisions and UM controls on both the pharmacy and medical benefit affect surveyed hematologist-oncologists’ choice of therapy.
Geography: United States.
Primary research: Survey of 30 U.S. hematologist-oncologists; survey of 30 U.S. managed care organization (MCO) pharmacy and medical directors (PDs/MDs).
Topics: Reimbursement and contracting; access and prescribing; opportunities and challenges for emerging therapies; disease-specific special topic.
Finger Formulary: Formulary coverage data for NHL / CLL therapies by commercial plans covering 163 million lives nationally and Medicare Advantage Part D plans covering up to 16.8 million lives.
Key drugs covered:
Rituxan, Gazyva, Imbruvica, Calquence, Venclexta, Yescarta, Kymriah, Tecartus, Breyanzi, Monjuvi, Polivy, Xpovio.
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.