Insurance

• Insurance coverage & prior-authorizationModerate

  Medicaid rules vary by state and plan — some don't clearly cover CAR-T, so approval can be slow or contested

• Coverage lag after approvalWatch

  State Medicaid can take months after FDA approval to add a new therapy, so coverage may not exist yet when it's needed

• Single-case agreement / out-of-networkWatch

  Medicaid out-of-state billing and enrollment are notoriously slow, stretching the time before treatment can start

• Equity / disparity riskModerate

  Medicaid patients meet more coverage restrictions and site limits, which lowers the chance of reaching treatment

Health-system navigation

• Equity / disparity riskModerate

  Harder to grasp eligibility, ask the right questions, and self-advocate — so these patients are identified and referred less often

• Language & communication barrierModerate

  Dense medical explanations may not land, so key instructions and warning signs can be missed unless teach-back is used

• Health-literacy / navigation-complexity burdenModerate

  The pathway spans dozens of visits, forms, and authorizations; without hands-on navigation, steps get missed and patients fall behind

Language

• Language & communication barrierModerate

  Without interpreters, eligibility discussions, consent, and toxicity instructions may not be understood — risking errors and delay

• Health-literacy / navigation-complexity burdenModerate

  A language barrier adds a translation layer to every form and instruction, slowing an already complex process

Household income

• Financial toxicity / out-of-pocket burdenHigh

  Copays, ancillary drugs, and travel stack up quickly and, on a limited income, crowd out essentials

• Travel & lodging burdenWatch

  On a limited income, uncovered travel and lodging can be the deciding factor in whether the patient actually shows up

Line of therapy

• Late referral / progression before treatmentWatch

  With 2+ lines already used, the window to refer while still eligible is closing

Financial cushion

• Financial toxicity / out-of-pocket burdenHigh

  With little savings, one unexpected bill or lost paycheck can halt participation mid-course

minority

• Equity / disparity riskModerate

  Documented referral bias and trial under-representation mean minority patients reach CAR-T less often at each step of the path

Income during treatment

• Financial toxicity / out-of-pocket burdenHigh

  Weeks away from work with no paid leave cut household income at exactly the moment costs are spiking