Cigna is launching a new solution as part of its health services business aimed at mitigating the high cost of emerging gene therapy treatments.
The Embarc Benefit Protection platform brings together expertise on medical management, health services and specialty pharmacy from Express Scripts, eviCore, Accredo and CuraScript SD, Cigna announced. The model is designed to alleviate high cost-sharing for patients and also prevent shock claims for employers and plan sponsors.
Health plans that adopt Embarc will pay a per-member, per-month fee to participate in a gene therapy network. Physicians will be required to submit prior authorization for the drugs, but once they’re approved a patient will not be charged a copay at the pharmacy counter.
Pharmacies and drug companies will be paid by Embarc for the therapies. At present, Cigna has listed two products for the program: Luxturna, a gene therapy treatment for people with inherited retinal disease, and Zolgensma, a treatment for children under two years old with spinal muscular atrophy—and the world’s most expensive drug.
Steve Miller, M.D., Cigna executive vice president and chief clinical officer, told FierceHealthcare that Embarc was built on three main principles: simplicity, affordability and predictability.
Eliminating a patient’s copay was a key focus in designing the program, he said. For example, someone with a $6,000 out-of-pocket maximum is not really making a substantial dent in the cost of a $2 million therapy, but they may be setting themselves up for bankruptcy.
In addition, these pricey drugs don’t have generic equivalents or alternatives, so having copayments isn’t enticing patients to shop around, Miller said.
Embarc also aims to push for greater value-based pricing in the system as the number of drugs with eye-popping prices continues to increase.
“We can’t just let pharma set the price on their own,” Miller said. “It’s got to go through a value assessment.”
Cigna plans to roll out the platform in several waves, first focusing on its own plans. In a second phase, Express Scripts will offer Embarc to its pharmacy benefit management clients outside of Cigna’s umbrella.
And finally, Miller said the company intends to offer these services to health plans, employers or other plan sponsors who are outside of Cigna and Express Scripts’ client base.
Cigna is also planning to expand the drugs included in Embarc in the future. Miller said it’s already working on determining the next group of drugs, including the potential for chimeric antigen receptor T-cell (CAR-T) therapies to be added. The Centers for Medicare & Medicaid Services announced last month that it would cover CAR-T, an emerging therapy for cancer, in some facilities.
“We’re already in the process of building that out,” Miller said.