– With its newly consolidated company, Cigna and Express Scripts are diving into the costly field of gene therapy and intend to increase members’ access through their new program, Embarc Benefit Protection.
“Expensive therapies for rare diseases pose a new challenge for America’s healthcare system, and this challenge will grow as more therapies are approved by the FDA,” Steve Miller, MD, Cigna’s executive vice president and chief clinical officer said in a press release. “We are leveraging our collective capabilities to deliver on the true promise of modern medicine. No cure should be out of reach of any patient, and they should receive the best quality care.”
The cost of gene therapies is escalating year by year. By 2024, the gene therapy industry will be worth as much as $15 billion, according to pharmacy data analysts at Evaluate.
Embarc Benefit Protection activates Cigna’s pharmacy benefit manager, Express Scripts; special medical benefits management company, eviCore; specialty pharmacy, Accredo; and specialty pharmacy distributor CuraScriptSD, Express Scripts.
eviCore enables Express Scripts to offer gene therapies without out-of-pocket expenses. The PBM contracts with payers, employers, HMOs, and health plans to become their in-network gene therapy provider.
Cigna Health and Life Insurance Company, a Cigna subsidiary, are among the payers that will offer Embarc Benefit Protection benefits. These organizations will pay eviCore a per-member per-month rate to participate in the gene therapy network.
The gene therapy network, which includes Accredo, consists of pharmacies that have contracted through CuraScript SD to provide gene therapies.
When a member covered by Embarc Benefit Protection is in need of gene therapy, the member’s prescriber will fill out and submit the necessary prior authorization. When the prior authorization is approved, eviCore reimburses the pharmacies and distributors providing the drug. The member can receive her therapy without an out-of-pocket cost.
“Payers that participate with us will be getting the best price. They will be getting uniform utilization management,” said Miller in a video on Cigna’s site. “They will also be getting this with just a cost recovery model for us, so we are not looking to profit off of this.”
At the moment, Embarc Benefit Protection offers members access to the two gene therapies approved in the United States: Luxturna, which treats inherited retinal disease, and Zolgensma, a drug for children under the age of two who have spinal muscular atrophy. The payer may make more therapies available through Embarc Benefit Protection.
This is a true test of industry consolidation, with the distributor, the middleman, and the payer all under the same company tackling one of the most significant prescription drug spending challenges in the nation.
Cigna underscored that this benefit is possible primarily due to its acquisition of Express Scripts last year.
Together, the companies also launched a program for members with diabetes earlier in 2019. The program, the Patient Assurance Program, enabled members to purchase approximately a month’s worth of insulin for a total of $25.
Public payers recently made strides in the direction of gene therapy as well.
In early August 2019, CMS made two gene therapies available to Medicare beneficiaries. The two CAR T-cell drugs, Kymriah and Yescarta, are a potential cure for non-Hodgkin lymphoma and B-cell precursor acute lymphoblastic leukemia.
When the public payer finalized the rule covering these treatments, CMS Administrator Seema Verma highlighted the significance of this move and of gene therapies.
“As the first type of FDA-approved gene therapy, CAR T-cell therapies are an important scientific advancement in this promising new area of medicine and provide treatment options for some patients who had nowhere else to turn,” said Administrator Verma.