Utilization Management in Non-Small Cell Lung Cancer

Growing drug costs in the United States are placing pressure on health plans to implement strategies to balance drug expenditures and utilization. Utilization management (UM) tactics are frequently used across public and private insurance plan types to control prescription drug spending. Though UM aims to lower costs for beneficiaries by evaluating different treatment options, it can also complicate the process for patients to obtain necessary medication, especially high-cost 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 provider-administered drugs that treat non-small cell lung cancer (NSCLC), including Imfinzi, Keytruda, Libtayo, Opdivo, and Tecentriq. The analysis focused on the medical benefit within the Medicare Advantage (MA) and commercial insurance markets in 2025 and 2026.

Both commercial and MA plans covered the analyzed NSCLC drugs 100% of the time across both years. MA plans placed NSCLC drugs in the non-preferred tier 30% of the time and in the preferred tier 7% of the time.

The analysis focused on step therapy (ST) requirements. All analyzed drugs are approved for first-line treatment, so 100% of ST policies were more stringent than the Food and Drug Administration (FDA) label. Commercial plans shifted from one to two step edits across all NSCLC drugs with ST, generally, though the total number of plan lives affected is small. MA plans only required one step edit across all drugs with ST for both years.