Aetna to cover multi-million dollar gene therapies

Aetna debuted a network focused on curbing the rising costs of the growing gene therapy market, the insurer announced on Thursday.

Structured like a Center of Excellence program, the company’s Gene-based Cellular and Other Innovative Therapies network includes more than 75 providers who treat inherited retinal disease—which impacts approximately 2 million people worldwide—and spinal muscular atrophy, which impacts an estimated 9,000 Americans. Treatment for these conditions comes in the form of gene therapy, where providers manipulate genes at the cellular level.

The U.S. Food and Drug Administration has currently approved 22 cellular and gene therapies, most of which are Chimeric Antigen Receptor T-cell treatments for cancer. But additional treatments targeting more common illnesses are in the pipeline, as drugmakers have invested in developing therapies that offer a one-time cure to rare and life-threatening disorders. Aetna anticipates nine new treatments to hit the market over the course of this year and next.

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These include some of the most expensive drugs on the market, like Novartis’ Zolgensma, a treatment for spinal muscular atrophy that hit the market in 2019 at more than $2 million for a single dose of the drug, making it the most expensive single-dose medication of all time. Providers in Aetna’s GCIT network will administer Zolgensma, Spark Therapeutics’ Luxturna and Biogen’s Spinraza. If federal regulators approve all the treatments in the pipeline, Aetna expects gene therapies to add an additional $45 trillion to healthcare costs between 2020 to 2024.

The company’s GCIT network will go live at the start of 2022, and is included as a benefit for the insurer’s fully- and self-insured customers, which represent approximately 34 million lives.

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

“Our multi-pronged approach encompasses safety, member access to cutting-edge therapies and cost management to support the medical and economic needs of our members and customers,” Richard Gentleman, executive director of national partner strategy, said in a news release. “It also paves the way for future-FDA-approved gene therapies to be added quickly and cost-effectively so that we can help more people achieve their best health.”

Through the network, members will have access to a care management team to help them navigate the healthcare system and their conditions. Aetna will also provide travel and lodging for members who must travel more than 100 miles for care.

The company will also offer a financial protection program for its CVS’ Caremark pharmacy benefit manager customers through this network, allowing them to spread the cost of a single-dose of gene therapy over several years.

For Aetna plan sponsors that do not have stop-loss coverage, the insurer allows customers to spread the actuarial risk of these high-cost medications across a pool of enrollees.

For government customers, Aetna said Medicaid programs disproportionately shoulder these care costs, since conditions like spinal muscular atrophy appear and require treatment early in a child’s life. The company expects “to see more evolution in how regulatory authorities look to manage the cost of these treatments,” the company wrote in a January white paper.

The GCIT network builds on Aetna’s National Medical Excellence Program, which debuted in 2018 and includes more than 120 providers that offer CAR-T cancer cell therapies, bone marrow and stem cell transplants.

Aetna is not the only insurer concerned about the rising cost gene therapies present.

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

At the end of last year, Centene Corp. closed its acquisition of PANTHERx, a pharmacy specializing in manufacturing orphan drugs and tools to treat diseases that affect fewer than 200,000 people in the U.S.

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

“Gene therapy is poised for significant growth in the coming years, and the promise of durable improvement for patients with challenging disease is exciting,” Dr. Joanne Armstrong, chief medical officer overseeing women’s health and genomics at CVS Health, said in a news release. “Yet, high costs associated with these therapies continue to pose a significant challenge. It is therefore vital that they are delivered by highly-specialized providers in an environment that can provide the patient receiving the therapy a high potential of a successful outcome.”