By Julie Alonso, Consultant & Casey Speer, Associate Partner

The oncology access landscape continues to tighten, with payers increasingly deploying step edits, utilization management (UM) controls, and formulary restrictions across therapeutic classes. What’s less well understood, and potentially just as consequential, is that provider wariness around coverage increasingly operates independently of actual payer policy for a given product. Physicians are making prescribing decisions based on an internalized model of the access environment, and that model doesn’t always reflect current reality for the therapy in front of them.

This is not a theoretical problem. A 2020 cross-sectional survey of physicians, referenced in a JAMA analysis by Resneck et al., found that 75% of respondents reported often avoiding evidence-based newer medications preemptively to circumvent anticipated prior authorization (PA) obstacles¹. The avoidance behavior was driven by expectation, not by actual denial. For manufacturers, that distinction represents a significant and addressable market access gap.

Competitive Classes Create Perception Spillover

The underlying reality is that payers are introducing increasingly restrictive measures in oncology. Where it becomes a perception problem is when class-level restrictiveness shapes provider assumptions about a specific product whose coverage has since stabilized. A new entrant can inherit the access reputation of the class it joins, independent of its own payer policy.

This effect is most pronounced in competitive therapeutic classes, where class saturation is actively driving payer restrictions. As multiple agents compete within the same indication, payers introduce preferred product policies (i.e., step requirements favoring lower-cost or generic alternatives, etc.). These restrictions are real, and they train providers to expect friction in that class broadly. When a new entrant arrives, or when an established product’s coverage improves, providers often apply the same restrictive mental model across the entire class regardless of product-specific policy. The availability of generics or biosimilars within a class compound this as payers lean on those lower-cost options as clinical gatekeepers, and providers internalize the step therapy logic even for patients where the clinical picture argues for a different sequence.

Regimen Complexity Impacts Coverage Assumptions

For treatments requiring specialized administration, patient monitoring, REMS programs, or coordination across care settings, providers often form negative coverage expectations before engaging with payer policy at all. The assumption is intuitive that if a therapy is complex to deliver, it must be complex to cover. That logic holds often enough to feel reliable; CAR-T therapies and bispecific antibodies, for example, do carry real administrative and financial hurdles. But the assumption can also overshoot, getting applied categorically to a class of therapies rather than calibrated to a specific product’s actual coverage requirements. The perception precedes the prior authorization request, and in some cases, precedes the prescribing decision entirely.

Early Launch Experiences Create Sticky Mental Models

Newly launched therapies face a predictable set of access challenges including NDC blocks while payer policies are established, absence of published prior authorization criteria, and formulary decisions still in process. Providers who encounter these during the launch window often internalize them as defining characteristics of the product’s access profile, and the perception persists. As coverage becomes established over a 6-to-12-month post-launch window, PA approval rates improve, but provider memory lags. In rare or niche oncology indications, a single difficult coverage experience can disproportionately shape perceptions across a practice, even when that experience no longer reflects how payer policy has evolved.

Denial Data Tells a More Nuanced Story

Prior authorization denials loom large in provider experience as they generate administrative burden, trigger peer-to-peer reviews, and delay treatment. But denial rates alone don’t tell the complete coverage story. A January 2026 KFF analysis of CMS Medicare Advantage data found that 80.7% of appealed prior authorization denials were partially or fully overturned². The initial denial, which is what providers remember, frequently does not represent where the final coverage decision ultimately stands.

Providers rarely complete the appeals loop for every denial. When a peer-to-peer call is burdensome or administrative infrastructure is limited, the path of least resistance is switching to an alternative therapy. The denial becomes the data point that shapes future prescribing behavior, even when the appeal outcome would have been favorable. Manufacturers who understand this dynamic can intervene at a specific and actionable point, helping providers understand that initial denials are often reversible and equipping practices with the tools to pursue that reversal efficiently.

What This Means for Manufacturers

  • Provider avoidance driven by anticipated access barriers is a documented behavioral pattern, and it represents a discrete commercial challenge that differs from actual payer restrictions.
  • Class saturation and the availability of generic or biosimilar alternatives are actively driving payer restrictions in competitive oncology classes; manufacturers need to help providers distinguish those class-level dynamics from the coverage profile of their specific product.
  • Therapy complexity creates its own perception layer; providers may assume coverage barriers for specialized treatments that don’t reflect actual payer policy, and manufacturers should proactively separate administrative process requirements from coverage restrictions in any provider-facing communications or reimbursement support materials.
  • Early launch access challenges create durable perception effects that require sustained, active education well past the launch window, particularly in low-volume indications.

The Opportunity Inside the Gap

The oncology access environment will continue to tighten, and provider caution will remain a rational response to it. The opportunity for manufacturers is not to argue that restrictions don’t exist, but to help providers accurately calibrate where their specific product stands within a landscape that varies considerably by therapy, indication, and payer segment. Manufacturers that bring that clarity, through real-world approval rate data, transparent PA guidance, and reimbursement support that reduces the cost of pursuing appeals, are better positioned to translate coverage into actual prescribing. The gap between what a payer policy says and what a provider assumes it says is addressable, and in an increasingly crowded oncology landscape, manufacturers who close it will have a meaningful edge over those who don’t.

Sources

¹Resneck JS Jr. et al. “Refocusing Medication Prior Authorization on Its Intended Purpose.” JAMA. 2020;323(8):703-704. https://doi.org/10.1001/jama.2019.21428

²Fuglesten Biniek J, Sroczynski N, Neuman T. “Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024.” KFF, January 2026. https://www.kff.org/medicare/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/