Gene therapies offer new hope to people with previously untreatable diseases linked to gene disorders. As increasing numbers of these groundbreaking therapies become available, many of them for less rare conditions such as sickle cell disease and hemophilia, plan sponsors need strategies to make them available to the patients who need them.
Evernorth Health Services recently announced it is expanding its Embarc Benefit Protection program, a solution that protects patients and plans against the high cost of gene therapies. The prices of existing gene therapies, which are set by drug manufacturers, range from $900,000 to more than $4 million. More than 1,000 gene and cellular therapies are in development, and more than 1,500 gene modification and cellular therapy trials (clinical studies) are in progress. As therapies emerge to target relatively common conditions, potential patient populations are expected to grow exponentially.
Under Embarc, patients qualifying for an included gene therapy receive personalized, expert care and have no out-of-pocket costs beyond their normal deductibles. Health plans pay a predictable, flat monthly fee to enroll and are eligible for annual reimbursements based on claims. Embarc currently covers nearly 7.2 million people and has provided $140 million in value to enrolled plans and patients in less than 5 years.
As a result of the expansion, patients with a wider range of conditions will be eligible for coverage for gene therapies with Embarc. Newly added therapies include Casgevy and Lyfgenia, both one-time gene therapies to treat patients with sickle cell disease. Lenmeldy, which treats patients with metachromatic leukodystrophy, will be added soon. Several other therapies are expected to be added throughout 2025.
“Embarc was built to help patients access life-changing gene therapies without bankrupting their employer’s health plan due to the extreme cost of these medicines. Four years later, we continue to deliver and build on those principles in the rapidly expanding world of gene therapies,” said Adam Kautzner, president of Express Scripts and Evernorth Care Management.
“As new and expensive gene therapies become available to treat diseases affecting larger patient populations, Embarc continues to offer simple, affordable, and comprehensive support to make the promise of these medicines a reality.”