A consensus is lacking on optimal treatment sequencing for follicular lymphoma (FL), the most common indolent lymphoma. FL is incurable, and many patients require multiple lines of therapy for successive relapses. Guidelines provide numerous recommendations for first-, second-, and third-line therapy; however, treatment patterns in the real world remain poorly understood. The primary objective of this study is to evaluate real-world treatment patterns among commercially insured patients with FL in the United States. A retrospective cohort of patients with newly diagnosed FL was identified from June 2008 to September 2016 using the IBM MarketScan® database. Treatment pattern measures, including time to treatment from diagnosis, days from previous line of therapy, duration of therapy, and distribution of treatment regimens among lines of therapy, were assessed. Descriptive statistics were reported for baseline characteristics, primary outcome, and treatment pattern measures. In total, 4232 patients were identified from the database and 2111 patients received at least 1 line of treatment. The most common first-line treatments included bendamustine + rituximab (39%), rituximab + cyclophosphamide + doxorubicin + vincristine (20%), and rituximab monotherapy (19%). Rituximab monotherapy was the most common second-line (34%) and third or greater line (57%) treatment. The median time from FL diagnosis to initiation of treatment was 50 days (interquartile range [IQR]: 28-191) for first-line treatment, 577 days (IQR: 312-1146) for second-line, and 776 days (IQR: 603-1290) for third-line. At a median follow-up of 3.6 years, most patients had 1 or fewer lines of therapy. The use of combination therapy decreased with each line of therapy and the numbers of patients receiving third- or fourth-line therapy were small in this study, potentially due to the short follow-up. Rituximab as monotherapy or in combination was utilized most frequently; however, the variety of other therapies used demonstrates that the standard management of FL remains unclear. Consensus on optimal treatment sequencing is currently lacking, and patients receive a variety of active regimens during routine practice. In this contemporary cohort of patients diagnosed with FL in the United States, rituximab therapy predominated both in monotherapy and in combination.