Cigna helps broaden access to life-changing gene therapies

When it comes to treating diseases, gene therapy may deliver truly transformational results. For example, gene therapy may improve sight for those with a specific inherited form of vision loss.¹ For others, born with spinal muscular atrophy, gene therapy may halt motor neuron loss and offers the potential for improved muscle function and longer, more productive lives.²

Gene therapy holds promise to treat a wide range of diseases, such as cancer, cystic fibrosis, heart disease and hemophilia – conditions caused by a dysfunctional or mutated gene. Gene therapies target the underlying cause of a disease at the cellular level by either replacing a faulty gene with a healthy copy of the gene or by adding a new or modified gene. This is often accomplished with a single treatment.

Cigna examines these factors when designating an individual product as a gene therapy:

Mechanism of action – The product either replaces a disease-causing gene with a healthy copy of the gene, inactivates a disease-causing gene that may not be functioning properly, or introduces a new or modified gene into the body to help treat a disease.
Considerations – This includes special handling and dispensing requirements, gene therapy administration, and required monitoring following the gene therapy administration.
Health care professional administration requirements – Gene therapies are usually administered in an outpatient hospital setting, though future gene therapies may require inpatient hospital administration.

Diligent provider contracting helps us to manage quality and gene therapy costs.
Our Cigna Gene Therapy Program contracts with providers who have access to gene therapy products. The program, introduced in January 2020, directs customers requiring gene therapy treatment to our participating providers. By collaborating with these providers, we strive to manage quality and control costs for the emerging realm of gene therapy.

The Cigna Gene Therapy Program features:

Supportive services from our dedicated gene therapy case management team.
In-network coverage only with Cigna Gene Therapy Program providers (except where state mandates require out-of-network coverage). Deductibles, copays and coinsurance apply under the customer’s current medical benefits.
A travel benefit (when traveling greater than 60 miles) to ensure customers get to the right facilities and receive the right attention and care.
Cost-effective care - by procuring therapies through Accredo^®, our Cigna specialty pharmacy, (when available) and negotiating deeper facility discounts where possible.
No additional administrative costs.

Integrated benefits with Cigna help ensure optimal support.
Our three key areas of focus when managing medical specialty treatments include: utilization, coordination of care, and management of associated costs. These factors are of utmost importance when managing customers who require gene therapies – which have the potential to change lives, but come with a significant price tag. In the U.S., annual gene therapy expenses are expected to reach more than $13.9 billion by 2026.³

When treatment with gene therapy becomes necessary, comprehensive support is key to help ensure each members’ overall treatment experience is a smooth one. Prior authorization is required for all gene therapies approved by the U. S. Food and Drug Administration and ensures customers meet the medical necessity criteria for each gene therapy. Our team of nurses are specialized to support the underlying indications of each gene therapy. They partner closely with a dedicated team of medical directors, including a board certified medical geneticist. This includes applying specific utilization management standards as well as the vast clinical expertise and strength from our combination with Express Scripts. This works to ensure customers meet the appropriate criteria to receive the gene therapy. Our high touch, comprehensive end-to-end case management between patients, families, and providers, includes multidimensional and emotional status assessments and ongoing engagement and follow-up after the gene therapy administration.

Cigna also offers Embarc Benefit Protection^SM to address high costs of gene therapies.
The Embarc solution is designed to help make revolutionary gene therapy drugs accessible to members with no out-of-pocket charges (members with a Health Savings Account ((HSA)) must meet the applicable minimum deductible required for high deductible health plans) or additional expense to the plan when covered under the plan and medically necessary. Clients pay a charge of $0.99 per member, per month (PMPM).

Embarc brings together the health services, medical management and specialty pharmacy expertise of Express Scripts, eviCore, and Accredo. It fills a critical need that offers a pathway for payers to provide coverage under their plans for potentially life-altering cures. They will now be within reach for individuals covered by a plan with an Embarc solution.

LEARN MORE

FDA approves novel gene therapy to treat patients with rare form of inherited vision loss. U.S. Food and Drug Administration. fda.gov. Dec. 18, 2017. <FDA approves novel gene therapy to treat patients with a rare form of inherited vision loss | FDA>.
FDA approves innovative gene therapy to treat pediatric patients with spinal muscular atrophy, a rare disease and leading genetic cause of infant mortality. U.S. Food and Drug Administration. fda.gov. May 24, 2019. < FDA approves innovative gene therapy to treat pediatric patients with spinal muscular atrophy, a rare disease and leading genetic cause of infant mortality | FDA>.
EvaluatePharma, Evaluate Ltd, London UK. www.evaluate.com Accessed 5/1/2020.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including eviCore healthcare MSI, LLC (d/b/a/ eviCore healthcare), Express Scripts, Inc., Accredo Health Group, Inc., or their affiliates. “Accredo” is a trademark of Express Scripts Strategic Development, Inc.