Utilization Management in Multiple Myeloma
As drug costs in the United States rise, health insurance plans are implementing strategies to balance expenditures and utilization. Plans can employ utilization management (UM) tactics to mitigate prescription drug spending. Though UM is used to lower plan spending and premiums for beneficiaries, it can also jeopardize patient access to necessary prescriptions, especially higher cost specialty products, such as oncology drugs.
To better understand the application of UM for oncology drugs, the American Cancer Society Cancer Action Network (ACS CAN) engaged Avalere Health to conduct an analysis on the coverage and UM practices of a subset of oral brand drugs that treat multiple myeloma, including Ninlaro, Pomalyst, Revlimid, Thalomid, and Xpovio. The analysis focused on the pharmacy benefit within the Medicare Part D insurance market, including Medicare Advantage-Prescription Drug plans (MA-PDs) and standalone Prescription Drug Plans (PDPs), and the commercial insurance market, in 2025 and 2026. Results indicate similar coverage for multiple myeloma drugs across all plan types in both years (80-84% of the time). The share of drugs not covered by MA-PDs and PDPs is driven by Revlimid, which has a generic available that was not included in the analysis. Drug tiering varies within commercial plans, with roughly equal placement in the preferred and specialty tiers, while MA-PDs and PDPs most frequently place multiple myeloma drugs on the specialty tier.
All plan types were found to have similar UM requirements across both years, with commercial plans requiring prior authorization (PA) less frequently (73% of the time) than MA-PDs (94% of the time) and PDPs (100% of the time). Though plans did not explicitly indicate step therapy (ST) within formularies, Avalere Health evaluated whether ST requirements were embedded within PA requirements across all plan types. Among plans imposing UM restrictions, commercial plans had embedded ST 44% of the time in 2025 and 45% of the time in 2026. MA-PDs had embedded ST 54% of the time, which decreased in 2026 to 46% of the time, while PDPs had embedded ST 64% of the time, which increased to 67% of the time in 2026.
