{"documentId":"1D2PayerLandscapeBrief2026_jkl654MnOpQrStUvWxYz","title":"2026 US Payer Landscape Brief — Zenvara","revisionId":"rev-1D2PayerLand","body":{"content":[{"sectionBreak":{"sectionStyle":{"columnSeparatorStyle":"NONE","contentDirection":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":41,"textRun":{"content":"2026 US Payer Landscape Brief — Zenvara\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"TITLE","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":287,"textRun":{"content":"Prepared by Aisha Bello, Senior Director of Market Access. Distribution: VP Commercial, Launch Lead, HEOR Director, KAM leadership. Covers the top 25 commercial plans, the top 10 Medicare Part D plans, the largest Medicaid Managed Care plans, and the federal payer landscape (VA, DoD).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":19,"textRun":{"content":"Executive summary\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"HEADING_2","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":527,"textRun":{"content":"Zenvara enters 2026 with established formulary positions at most of the top 10 commercial plans following an aggressive Q4 2025 contracting cycle. The two notable exceptions are Aetna (tier 4 with step-therapy through pembrolizumab, effective Jan 1, 2026 — booked as a loss in the win/loss log) and Humana Gold Plus HMO (non-formulary, exception only). The Cigna win in November 2025 — preferred tier 3 with PA only, effective July 1, 2026 — is the largest single net-positive change in the Zenvara payer landscape this year.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":332,"textRun":{"content":"Net price erosion across the book is modeled at 4-6% YoY, driven primarily by IRA Part D rebate restructuring. The top three PBMs (CVS Caremark, Express Scripts, OptumRx) collectively account for roughly 78% of commercial Zenvara lives covered; their 2026 NPF refreshes happen in late Q3 and represent the dominant near-term risk.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":354,"textRun":{"content":"UnitedHealthcare remains the highest-leverage commercial negotiation — both the largest single payer by lives and the lowest-friction contracting counterpart. The recent operational change at UHC (PA turnaround drift from 4 to 9 days, observed in April and confirmed in the May 12 internal review) is the single most material near-term commercial risk.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":41,"textRun":{"content":"Top 5 commercial plans by lives covered\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"HEADING_2","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":218,"textRun":{"content":"1. UnitedHealthcare Group — 51M commercial lives (OptumRx). Zenvara position: tier 3 preferred with PA. Performance: -22% vs plan in April-May 2026 due to PA latency drift. Risk level: HIGH (acute operational issue).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":196,"textRun":{"content":"2. Anthem/Elevance Health — 45M commercial lives (CarelonRx). Zenvara position: tier 3 with PA + ST. Performance: -3% vs plan. Risk level: MEDIUM (stable but Anthem renegotiation cycle Q3 2026).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":265,"textRun":{"content":"3. CVS Health/Aetna — 24M commercial lives (CVS Caremark). Zenvara position: tier 4 with step-therapy effective Jan 1, 2026. Performance: stable but suppressed. Risk level: MEDIUM (step-edit appeal cycle ongoing; cannot escalate without re-opening 2026 contract).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":223,"textRun":{"content":"4. The Cigna Group/Evernorth — 18M commercial lives (Express Scripts). Zenvara position: tier 3 preferred with PA only, effective July 1, 2026. Performance: ramping. Risk level: LOW (recent win, established relationship).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":216,"textRun":{"content":"5. Humana — 17M commercial lives (Humana Pharmacy Solutions). Zenvara position: not on commercial formulary. Performance: minimal. Risk level: LOW (small commercial book; Humana's volume is concentrated in Part D).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":43,"textRun":{"content":"Top 5 Medicare Part D plans by membership\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"HEADING_2","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":106,"textRun":{"content":"UnitedHealthcare Medicare Advantage (Optum Rx): preferred tier with PA, 9.8M lives. Performance on plan.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":179,"textRun":{"content":"Humana Gold Plus HMO (Humana Pharmacy Solutions): non-formulary, exception process only. 8.9M lives. Significant access gap; appeal cycle continues but unlikely to land in 2026.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":89,"textRun":{"content":"Aetna Medicare (CVS Caremark): preferred tier with PA, 3.4M lives. Performance on plan.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":94,"textRun":{"content":"Centene WellCare (Express Scripts): preferred tier with PA, 4.5M lives. Performance on plan.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":102,"textRun":{"content":"Humana Walmart Value Rx (Humana Pharmacy Solutions): not pursued (low Zenvara fit, value-tier plan).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":22,"textRun":{"content":"PBM market structure\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"HEADING_2","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":128,"textRun":{"content":"Express Scripts (Cigna Group): 31% of US prescription claims. Zenvara NPF status: included tier 3 with PA, effective May 2026.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":115,"textRun":{"content":"CVS Caremark (CVS Health): 26% of claims. Zenvara NPF status: included tier 3 with PA + ST through pembrolizumab.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":142,"textRun":{"content":"OptumRx (UnitedHealth): 23% of claims. Zenvara NPF status: included tier 3 with PA. Same UHC-side PA workflow currently flagged for latency.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":102,"textRun":{"content":"Humana Pharmacy Solutions: 8% of claims. Zenvara NPF status: limited to Aetna-aligned product books.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":124,"textRun":{"content":"Prime Therapeutics (BCBS): 5% of claims. Zenvara NPF status: included tier 3 with PA at the 7 largest BCBS regional plans.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":115,"textRun":{"content":"MedImpact: 3% of claims. Zenvara NPF status: included tier 3 with PA in regional Medicaid Managed Care contracts.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":23,"textRun":{"content":"Medicaid Managed Care\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"HEADING_2","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":417,"textRun":{"content":"Zenvara is included on Preferred Drug Lists in 21 states with step-edit through pembrolizumab in 14 of those. The Florida AHCA PDL refresh on May 11, 2026 moved Zenvara from preferred to non-preferred with mandatory step-edit — booked as a loss in the win/loss log. Internal monitoring of state PDL refreshes is weekly; the FL refresh landed on a Sunday and was not registered internally until the following Friday.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":254,"textRun":{"content":"The largest Medicaid Managed Care plans are UnitedHealthcare Community Plan (7.2M), Anthem Medicaid (6.4M), Molina Healthcare (5.1M), Aetna Better Health (2.9M), and Centene WellCare (Medicaid; 4.5M). Combined Medicaid lives covered: approximately 26M.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":16,"textRun":{"content":"Federal payers\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"HEADING_2","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":142,"textRun":{"content":"VA National Formulary: Zenvara included as of February 2026, no restrictions beyond the standard VA oncology pathway. 9.0M veterans covered.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":116,"textRun":{"content":"DoD TRICARE: Zenvara included effective January 2026, preferred tier with PA. 9.5M military beneficiaries covered.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":86,"textRun":{"content":"340B coverage: standard 340B pricing applies. No 340B-specific contracting in place.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":9,"textRun":{"content":"Pricing\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"HEADING_2","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":112,"textRun":{"content":"Wholesale acquisition cost (WAC): $14,000 per 480mg vial. At Q6W dosing, annualized WAC per patient: $122,000.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":96,"textRun":{"content":"Average commercial net price (after rebates): $93,200 per patient per year (gross-to-net 24%).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":85,"textRun":{"content":"Average Medicare Part D net price: $84,500 per patient per year (gross-to-net 31%).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":116,"textRun":{"content":"Average Medicaid net price: $61,200 per patient per year (gross-to-net 50%, including statutory Medicaid rebates).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":183,"textRun":{"content":"Blended net price across the book: $87,400. Net revenue per patient is ultimately driven by mix; commercial-heavy quarters yield ~3% higher blended net than Medicare-heavy quarters.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":12,"textRun":{"content":"IRA impact\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"HEADING_2","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":342,"textRun":{"content":"Zenvara is a small-molecule biologic and therefore eligible for IRA Medicare Drug Price Negotiation Program on the standard 7-year post-approval timeline. Selection eligibility window opens January 1, 2032. The current modeling assumes Maximum Fair Price implementation effective 2034. See IRA Negotiation Impact Analysis (1G6…) for detail.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":295,"textRun":{"content":"The near-term IRA effect is the Part D rebate restructuring (effective 2025 and 2026) which has reduced manufacturer rebate liability while increasing manufacturer responsibility in the catastrophic phase. Net impact on Zenvara Part D economics: approximately -3.5% to -4% per beneficiary YoY.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":28,"textRun":{"content":"Negotiation cycle calendar\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"HEADING_2","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":60,"textRun":{"content":"Q1 2026 (Jan-Mar): annual rebate true-ups with top 5 PBMs.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":89,"textRun":{"content":"Q2 2026 (Apr-Jun): mid-year operational reviews (UHC operational issue addressed here).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":117,"textRun":{"content":"Q3 2026 (Jul-Sep): 2027 NPF submissions due to Express Scripts (July 1), CVS Caremark (July 15), OptumRx (July 30).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":176,"textRun":{"content":"Q4 2026 (Oct-Dec): contract renewals with Aetna (December effective Jan 1, 2027) and tactical pull-through on 2027 Medicare Part D bids (CMS bid cycle finalized August 2026).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":22,"textRun":{"content":"Watch items for 2026\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"HEADING_2","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":229,"textRun":{"content":"ESI 2027 NPF refresh: high probability (~70%) that ESI imposes a step-edit through pembrolizumab as part of the 2027 cycle. Mitigation: defensive clinical data package preloaded; subgroup analysis on PD-L1≥50% prepared by HEOR.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":210,"textRun":{"content":"Anthem closed-formulary states: probability (~60%) that Anthem moves to closed formulary in 4 BCBS-aligned states (Indiana, Kentucky, Ohio, Virginia). Mitigation: KAM-led engagement with state P&T committees.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":161,"textRun":{"content":"CMS PA workflow audit: CMS-issued guidance on Part D PA workflows is expected in Q3 2026; impact on Zenvara's Part D PA criteria unclear but likely manageable.\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":18,"textRun":{"content":"Cross-references\n","textStyle":{"bold":true}}}],"paragraphStyle":{"namedStyleType":"HEADING_2","direction":"LEFT_TO_RIGHT"}}},{"paragraph":{"elements":[{"startIndex":1,"endIndex":145,"textRun":{"content":"Formulary Win/Loss Log (1E7…), Payer Objection Handling Playbook (1F1…), IRA Negotiation Impact Analysis (1G6…), Zenvara US Launch Plan (1V3…).\n","textStyle":{}}}],"paragraphStyle":{"namedStyleType":"NORMAL_TEXT","direction":"LEFT_TO_RIGHT"}}}]},"documentStyle":{"pageNumberStart":1,"marginTop":{"magnitude":72,"unit":"PT"},"marginBottom":{"magnitude":72,"unit":"PT"},"marginLeft":{"magnitude":72,"unit":"PT"},"marginRight":{"magnitude":72,"unit":"PT"},"pageSize":{"height":{"magnitude":792,"unit":"PT"},"width":{"magnitude":612,"unit":"PT"}}},"namedStyles":{"styles":[{"namedStyleType":"NORMAL_TEXT","textStyle":{"fontSize":{"magnitude":11,"unit":"PT"}}},{"namedStyleType":"TITLE","textStyle":{"fontSize":{"magnitude":26,"unit":"PT"},"bold":true}},{"namedStyleType":"HEADING_1","textStyle":{"fontSize":{"magnitude":20,"unit":"PT"},"bold":true}},{"namedStyleType":"HEADING_2","textStyle":{"fontSize":{"magnitude":16,"unit":"PT"},"bold":true}}]},"lists":{},"inlineObjects":{},"headers":{},"footers":{},"footnotes":{},"suggestionsViewMode":"DEFAULT_FOR_CURRENT_ACCESS"}