The world of gene therapies is experiencing an explosive growth cycle. In fact, it’s anticipated to have a potential $42 billion dollar impact to the health care industry in the next five years1. The FDA estimates 10 to 20 cell and gene therapies will be approved every year through 20252. These drugs are life-changing and can improve and even extend the lives of recipients.
What is gene therapy?
Gene therapy refers to techniques used in medicine that modify a person’s genes to either treat or cure disease. Currently, gene therapy products are being explored for their role in treating cancer, genetic illnesses, infectious diseases and more. Though still being studied, they hold tremendous promise for treating a long list of diseases, such as heart disease, cystic fibrosis, diabetes and hemophilia, to name a few.
As the science and health care market evolve, there will be more opportunities to offer these transformational new options to health plan subscribers. However, this cutting-edge therapy also comes at an enormous cost. This can leave many employers struggling to find ways to offer coverage with price tags for a single treatment averaging three million dollars3.
How Meritain Health® is providing end to end support
We know both how important gene therapies are to our members and how complex these treatments can be. At Meritain Health, we’re proud to have the processes in place to provide quality and cost controls and extensive review at each point in a complex process.
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- Creating simplicity through coordination. Our case management team helps members navigate their benefit language, coverage, providers, pharmacy benefits management and specialty drug manufacturers involved in their treatments. Our dedication to members and plan sponsors—plus unrivaled connections to Aetna resources—allow us to offer opportunities that reduce costs without ever sacrificing quality.
- Robust provider access. We provide access to Aetna® Gene-based, Cellular and Other Innovative Therapy (GCIT) Designated Network. This is a unique network of quality, approved and contracted physicians able to provide quality care and delivery at pre-negotiated costs. To keep things simple, we also provide a convenient provider directory to help members see if a provider is in-network.
- Expert market monitoring. New gene therapy drugs are being approved rapidly by the FDA. Through GCIT, Aetna experts monitor the pipeline for thorough review of new treatments. Aetna produces clinical policy bulletins that outline the clinical guidelines for meeting medical necessity. Currently, all gene therapies are managed under medical benefits.
- Versatile plan design. Our ability to customize benefit design and plan language helps steer our members to cost-effective options. This ensures excellent support for them and cost containment for the plan sponsors we work with.
- Unique pharmacy benefits. Combining pharmacy, medical management and cost management helps connect clients and members to the right solutions when they need them most. By leveraging our relationship with CVS Health® and Meritain Health Pharmacy Solutions (MPS), we’re ideally positioned to deliver financial value and unique clinical solutions.
- Financial transparency. Meritain Health offers stop loss options and coordination, as well as bill audit and review of high-cost claims to help protect a better bottom line.
Meritain Health is well equipped to show you the way through all of the complexity around gene therapies. We do this by leveraging the powerful connections we have, both through the components Aetna offers as well as our own versatility.
For more information about gene therapies, contact your Meritain Health representative.
Sources:
1Aetna/Caremark economic modeling Jan/23
3https://www.fda.gov/vaccines-blood-biologics/cellular-gene-therapy-products/what-gene-therapy
https://www.mayoclinic.org/tests-procedures/gene-therapy/about/pac-20384619#:~:text=Gene%20therapy%20holds%20promise%20for,part%20of%20a%20clinical%20trial
