Aetna Covers Multimillion-dollar Gene Therapies

The insurance company announced Thursday that Aetna has unveiled a network aimed at containing rising costs in the growing gene therapy market.

The company’s network of gene cell and other innovative therapies, structured as a Center of Excellence program, includes more than 75 vendors that treat hereditary retinal diseases, which affect about 2 million people worldwide, and spinal muscular atrophy, which affects approximately 9,000. Americans. Treatment for these conditions is in the form of gene therapy, where providers manipulate genes at the cellular level.

United States FDA currently approved 22 cellular and gene therapies, most of which are T cell therapy for a chimeric antigen receptor to treat cancer. But additional treatments for more common diseases are in development as drug manufacturers have invested in developing treatments that offer one-off treatments for rare and life-threatening diseases. Aetna expects nine new drugs to hit the market this year and next.

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These include some of the most expensive drugs on the market, such as Novartis’ Zolgensma, a treatment for muscular atrophy of the spine that hit the market in 2019 for over $ 2 million per dose, making it the most expensive single-dose drug. medicines for all time. Providers in the GCIT Aetna network will administer Zolgensma, Spark Therapeutics’ Luxturna and Biogen’s Spinraza. Aetna expects that if federal regulators approve all planned treatments, gene therapy will increase healthcare spending by $ 45 trillion between 2020 and 2024.

The company’s GCIT network will launch in early 2022 and will be included as a benefit for the insurer’s fully insured and self-insured clients, who represent approximately 34 million lives.

Aetna, owned by CVS Health, did not respond to an interview request.

“Our multi-pronged approach includes safety, member access to advanced treatment and cost management to meet the medical and economic needs of our members and clients,” said Richard Gentleman, executive director of national partner strategy in a press release. “It also paves the way for the rapid and cost-effective addition of FDA-approved gene therapies so that we can help more people achieve their best health.”

Through the network, participants will have access to a health care management team to help them navigate the health care system and their settings. Aetna will also provide travel and accommodation for members who need to travel more than 100 miles to receive medical assistance.

The company will also offer a financial safeguard program through the network to its Caremark CVS pharmacy clients, allowing them to spread the cost of a single dose of gene therapy over several years.

For sponsors of the Aetna plan who do not have a stop loss, the insurer allows clients to share the actuarial risk of these expensive drugs among the members.

For government customers, Aetna said Medicaid disproportionately covers these care costs as conditions such as muscular atrophy of the spine appear and require treatment early in a child’s life. The company expects to “see further developments in the way regulators look at managing the costs of these treatments,” the company wrote in a January white paper.

The GCIT network is based on the Aetna National Medical Excellence Program, which debuted in 2018 and includes over 120 providers offering CAR-T cancer cell therapy, bone marrow and stem cell transplants.

Aetna isn’t the only insurance company worried about the rising cost of gene therapy.

Come January 2022, UnitedHealth Group will offer some self-insured clients a gene therapy risk protection program, a stop loss product that allows plan sponsors to pay a fixed monthly premium per member in exchange for claim protection. In 2019, the company paid $ 300 million to purchase a specialized pharmacy, Diplomat.

At the end of last year, Centene Corp. closed the acquisition of PANTHERx, a pharmacy specializing in orphan medicines and instruments for the treatment of diseases affecting fewer than 200,000 people in the United States.

Cigna also offers gene therapy protection plan for self-insured customers.

“Gene therapy is poised for significant growth in the coming years, and the promise of lasting improvement in patients with severe illness is exciting,” said Dr. Joan Armstrong, Chief Medical Officer for Women’s Health and Genomics at CVS Health in a press release. … “However, the high costs associated with these treatments remain a major challenge. It is therefore vital that they are provided by highly specialized providers in an environment that can provide the patient receiving therapy with a high potential for success. ”

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