Cigna/Express Scripts Gene Therapy Solution Involves Plans ‘Pre-Paying’ For Coverage
Approach designed to avoid price “shock” when coverage for Luxturna or Zolgensma is requested. Plans would agree to certain per member per month payments to enroll in the program, which would cover both plan and patient costs for gene therapy.
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Value-based contracting in the US is moving toward high-cost drugs for rare disease and away from lower cost chronic treatments as payers plan for the coming pipeline of cell and gene therapies. Marketed gene therapies all have some kind of risk sharing deal in place but further progress on the most innovative payment models is hampered by regulatory and operational challenges. The Centers for Medicare and Medicaid Services has taken a first step toward addressing regulatory obstacles but there is a long way to go.
Former US FDA commissioner Scott Gottlieb makes a case for regional or national risk pools to ensure pediatric patients get timely access to gene therapy like the upcoming treatments for sickle cell disease.
Novel reimbursement scheme allowing payers to spread out the cost of an expensive gene therapy over time may get test drive with Spark's Luxturna before being used for big-market treatments for hemophilia.