Payer Access, Cost Recovery, and Patient Assistance for Bispecific Antibodies

CancerNetwork® spoke with Ralph V. Boccia, MD, FACP, founder of The Center for Cancer and Blood Disorders, clinical associate professor at MedStar Georgetown University Hospital, and medical director of the International Oncology Network Clinical Research Program, about access, reimbursement, and cost considerations for bispecific antibodies. Boccia discussed how buy-and-bill models have expanded access, how national and regional payers differ in their authorization processes, and how cost recovery factors into drug selection after safety and efficacy. He also addressed coverage denials for second-line teclistamab-tcyv (Tecvayli) plus daratumumab and hyaluronidase-fihj (Darzalex Faspro), which the FDA approved in March 2026 based on the phase 3 MajesTEC-3 trial (NCT05083169),^1,2 and described the manufacturer patient assistance programs that help patients manage out-of-pocket costs.

CancerNetwork: What payer engagement models have sped up access to newer immunotherapies?

Boccia: Most of the models today are almost all buy-and-bill, so access to these drugs has expanded greatly. Because the payers aren’t that used to these drugs yet, we haven’t seen much in the way of step edits, where they’re picking a drug for us. Someday that probably will be the case, as they begin to contract with the manufacturers as well. But right now, if you’re following the guidelines, which depend on the line of therapy the drug is approved in, payers are supporting authorizations.

How do national and regional payers differ in their authorization processes?

Boccia: That’s a real problem for us, only in the sense that, as you point out, even though it may be a national carrier, the guidelines and the authorizations are managed by the local groups themselves, so each state and region is different. The experience of many of my colleagues in dealing with payers and getting prior authorizations and approvals relatively quickly varies from place to place. As we now see bispecifics being adopted more, payers are coming to the understanding that as long as we’re following the guidelines, the approvals, or both, they have no choice but to authorize payment.

How do cost and cost recovery factor into inpatient vs outpatient administration?

Boccia: Cost recovery is an interesting thing. Cost recovery is the way we keep our lights on. The manufacturers dictate the cost of the drug, and then the groups themselves, whether they be group purchasing organizations, individual groups, or individual networks, work with the manufacturer to try to contain the cost by lowering it, so they can offer a lower cost to the patients. When we look at drugs, that’s one of the factors. When we look at a drug and we have different options, as we obviously do in myeloma and lymphoma, the first factor is safety. If one drug is safer and more efficacious, that’s king. It doesn’t matter the cost; safety and efficacy are king. From there, it’s looking at routes of administration, at cost recovery, as you call it, and at convenience for the patient.

Have you ever had coverage denials for second-line teclistamab/daratumumab, and how did you handle them? Does approval differ between inpatient and outpatient administration?

Boccia: We’ve had an occasional payer that did not want to pay for the drug because the label said the patient needs to be observed in the hospital during step-up dosing, but we’ve been able to convince them that we can do it in a much more economical way without sacrificing safety. The payers, are interested in their costs, and we know from experience with all the drugs we use that when a patient goes to the hospital, the cost goes up multiple fold, probably somewhere between 5- and 20-fold. We have worked with the manufacturers as best we can to help payers understand how much cost we can save them and how we can make it more convenient and commodious for the patients.

The patients don’t want to be in the hospital. Their families don’t want them in the hospital. Hospitals are places where people get sick, so being in the hospital is not a positive thing unless you need very specific care that cannot be delivered in the outpatient setting.

Are patients facing high out-of-pocket costs for second-line teclistamab/daratumumab even after approval, and does that change your regimen choice? Are there patient assistance programs to help?

Boccia: The beauty of working with the manufacturers is that they realize, and have for a long time, that they’ve got to make their therapies affordable. The way they do that is they work with the payer and with the clinic to provide that. With every single drug that gets approved, one of the first things you hear as it’s coming out the door is what its patient assistance programs look like, what its suite of services is, and what assistance it offers with prior authorizations. Manufacturers work with payers to make sure the drug is on their formulary, and that is very helpful.

Copay cards, initial free drug, and bridging therapy, for example when people change insurance and have a gap in coverage, allowing that bridge to be covered with free drug: all those things are very helpful. Education, peer support, nursing support, that whole suite of services: all the manufacturers do a pretty good job of providing it, some a little better than others, especially financially. Most of them will not let a patient go without the drug because they’re not covered at the time. They have programs that will provide drugs to help patients out.

References

1. FDA approves teclistamab in combination with daratumumab hyaluronidase-fihj for relapsed or refractory multiple myeloma. News release. FDA. March 5, 2026. Accessed October 9, 2026. https://tinyurl.com/54fmbpr4
2. Costa LJ, Bahlis NJ, Perrot A, et al. Teclistamab plus Daratumumab in relapsed or refractory multiple myeloma. N Engl J Med. 2026;394(8):739-752. doi:10.1056/NEJMoa2514663