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Deep dive into CGT coverage
Download a detailed checklist and review the next steps and conversation starters to help you evaluate CGT coverage for your organization.
Download checklistThis is
Cell and Gene
Therapy.
This is an innovation
in disease treatment.
Navigating the integration of Cell and Gene Therapies (CGT) into a health benefits design requires careful planning and ongoing management. By referring to these key considerations, comprehensive support can be provided to employees while trying to manage financial risk effectively.
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The potential
impact of CGT
CGT is a novel approach that often helps address the root causes of disease and may be the only treatment needed to help improve a patient’s life1 and potentially prevent disease progression.2 With the right benefit structure, CGT has the potential to help offset costs of long-term medical interventions and treatment for your employees.1
Getting started:
CGT employer educational resources
As an employer, learning about the CGT landscape and its potential impact on your organization can be key to building CGT into benefits plans.
Navigating the financial landscape of cell and gene therapies: Understanding cost drivers & innovative payment solutions
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Conversation
1
What is the likelihood that our organization will see a claim for a CGT, based on our employee population and current market availability?
2
How are CGTs covered under our COC (Certificate of Coverage)?
- Does our COC include all CGT, or only select therapies?
- Are they covered under the pharmacy benefit or the medical benefit?
- What CGT-related cost limits and requirements for out-of-pocket expenses are specified within our current policy?
3
Is there a prior authorization process for CGT within our current policy?
- What are the criteria, and who will support claim review and approval decisions?
4
How does our plan cover CGT in the case of referrals into COEs (Centers of Excellence)?
5
Does our plan cover relevant genetic testing?
6
How are we currently protecting our risk in the event of a CGT claim?
- With these solutions, how much would we pay for each CGT claim, and how can we enhance our options to better protect against financial exposure?
7
How does our stop-loss insurance cover CGT claims?
- Does it include all CGT or only select therapies?
- Are there CGT-specific riders or policies?
- Are there specific limitations, exclusions, lasers, or adjusted cost sharing we should be aware of?
8
Are we eligible to enroll in other programmatic offerings from national plan carriers or third parties?
- What services do they provide, and what are the associated costs and benefits?
Understanding the benefits and challenges of cell and gene therapy
In the dynamic world of healthcare advancements, understanding the impact of emerging treatments like Cell and Gene Therapies (CGT) is essential for making informed decisions about employee health benefits.
Cell and Gene Therapies have the potential to help address the root causes of disease and may only require a one-time administration.1 For many patients, these therapies could mean fewer hospital visits, reduced need for ongoing treatments, and in some cases, a potential cure.1,6,7 When administered early enough, CGTs may potentially prevent disease progression.2
Managing Cell and Gene Therapy costs
The unique nature of CGTs and their complex manufacturing processes contribute to the high cost per treatment, typically ranging from $250,000 to $3.5 million per individual.8 For employers considering CGT in health benefits plans, understanding these costs is essential. The high initial investment should be evaluated against providing potential long-term savings and improved patient outcomes, which may benefit both employees and employers.1
References
References
01
Salzman R, et al. Addressing the value of gene therapy and enhancing patient access to transformative treatments. Mol Ther. 2018;26:2717-2726. htps://doi.org/10.1016/j.ymthe.2018.10.017
02
Gene Therapy Approaches. American Society for Cell and Gene Therapy. Accessed December 18, 2024. https://patienteducation.asgct.org/gene-therapy-101/gene-therapy-approaches
03
Wong CH, Li D, Wang N, et al. The estimated annual financial impact of gene therapy in the United States. Gene Ther. 2023;30:761-773. https://doi.org/10.1038/s41434-023-00419-9
04
Young CM, et al. Durable cell and gene therapy potential patient and financial impact: US projections of product approvals, patients treated, and product revenues. Drug Discov Today. 2022;27(1):17-30. https://doi.org/10.1016/j.drudis.2021.09.001
05
Deloitte. “Innovative CGT Financing Models.” Deloitte United States, Deloitte Development LLC. Accessed December 19, 2024. https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/innovative-cgt-financing-models.html
06
Melenhorst JJ, et al. Decade-long leukaemia remissions with persistence of CD4+ CAR T cells. Nature. 2022;602:503-509. https://doi.org/10.1038/s41586-021-04390-6
07
Johnson PC, et al. Longitudinal patient-reported outcomes in patients receiving chimeric antigen receptor T-cell therapy. Blood Adv. 7, 2023;7:3541-3550.
08
Apex Benefits. Benefits insight: cell and gene therapy cost management. May 24, 2023. Accessed December 18, 2024. https://apexbg.com/gene-therapy-cost-management/