Trends in Utilization Management for Oncology Therapies Amongst US Commercial Health Plans: 2017-2024

Historically, commercial health plans have applied utilization management (UM) less frequently to oncology treatments than to drugs in other therapeutic areas although this may be changing. We evaluated trends in UM for oncology therapies from 2017 to 2024, examined variation across health plans and drug characteristics, and assessed evidence sources cited in coverage policies.

We used the Tufts Medical Center Specialty Drug Evidence and Coverage Database, which contains publicly available coverage policies and cited evidence from 18 large US commercial health plans representing approximately 70% of the market. We analyzed 5,419 oncology coverage policies for 363 drug-indication pairs active as of August 2024. We identified UM criteria imposed beyond US Food and Drug Administration label indications, including subgroup restrictions, step therapy, and prescriber requirements, and compared their use with that for nononcology drugs. We also examined temporal trends, variation across plans, and plans' citation of clinical evidence and National Comprehensive Cancer Network (NCCN) guidelines.

In August 2024, 35.2% of oncology coverage policies included UM, compared with 73.2% for nononcology policies. UM use varied across plans (12.1%-40.0%) and was more common for cell and gene therapies, biologics, and products with biosimilar or generic competition. Excluding prescriber requirements, oncology UM increased from 14.5% in 2017 to 22.9% in 2024, driven primarily by step therapy growth (4.3%-16.5%). Most oncology coverage policies referenced NCCN guidelines.

Although UM remains less common for oncology therapies than for nononcology drugs, its use has increased in recent years, particularly through step therapy protocols, and varies widely across health plans. These findings highlight the growing role of UM in oncology and the important implications for treatment sequencing, administrative burden, and patient access.