Financial protection from Specialty Pharmacy

We are all familiar with the substantial financial impact treating Specialty conditions can have on total healthcare budgets. Specialty drugs have become the fastest-growing, largest segment of the total pharmacy market in the U.S. Though they represent only a small percent of prescription volume, they account for about a quarter of healthcare spend.1

When you have integrated medical and pharmacy with Cigna, we have a broad suite of solutions in place that aim to control Specialty drug costs, utilization, and site of care. These solutions all work together to manage trend and help bring down total spend.

Another key component to managing healthcare budgets is preparing for the unexpected. The fact is that no employer can anticipate when a covered employee may need to start a Specialty condition treatment plan. Certainly, no employer can predict that an even costlier treatment choice may be required. For example, gene therapy can often cost over $2 million for just one life-saving dose.2

At Cigna, we watch the Specialty drug pipeline every day. Meanwhile, we consistently work hard to come up with new solutions and coverage options that can meet the changing need for Specialty drugs.  We also have several notable solutions in place that help provide financial protection for our clients in case of those “lightning strike” moments.

Managing financial assistance
The cost of Specialty medications and the increased adoption of high-deductible health plans (HDHP) have placed a higher financial burden on patients. As out-of-pocket costs increase—from higher costs or insurance denials—patients may be more likely to abandon their treatment plans. That’s why we make affordability key, while managing the financial impact on our clients.

At Accredo®, our Cigna specialty pharmacy, we have dedicated financial assistance teams who help customers pay for their medications. In fact, about 98% of Specialty medications at Accredo have a manufacturer or third-party assistance program available to those who qualify.3 And In 2021, financial assistance coordination from the Accredo Therapeutic Resource Centers (TRCs) helped customers achieve about $1.7B in copay assistance.3

We also have two programs in place to ensure that we manage copay assistance the right way for our clients too:

  • SaveOnSP* – Customers pay $0 out of pocket for certain specialty medications, which are classified as non-essential health benefits and no longer count toward the plan deductible and out-of-pocket amounts.
  • Out of Pocket Adjuster – Customers can still use manufacturer copay assistance. However, the amount contributed by pharmaceutical manufacturers does not apply to the customer’s deductible or out-of-pocket maximums.

Holding pharma accountable
Through our combination with Express Scripts®, we strengthened our ability to contract with drug manufacturers. Specifically, we launched SafeGuardRx for Cigna®, a program that holds pharmaceutical manufacturers accountable for the value and efficacy of select high-cost therapies, at no additional cost to our clients.

With this value-based program, we limit our ASO clients’ financial exposure and drive down costs for certain complex, costly conditions. These include inflammatory, oncology, multiple sclerosis, preventive migraine and epilepsy, acute migraine, cardiovascular and rare conditions. Depending on the condition, cost control may take the form of either discontinuation credits, use threshold credits, or cost caps on medications.

Making gene therapy affordable
Our Cigna Gene Therapy Program contracts with providers who have access to gene therapy products, helping us manage quality and control costs for this growing market. We also offer Embarc Benefit ProtectionSM to make gene therapy drugs accessible to members with no out-of-pocket charges. Clients simply pay a flat per member, per month (PMPM) charge.

Embarc brings together the health services, medical management and Specialty pharmacy expertise of Accredo, Express Scripts Pharmacy (our home delivery pharmacy), and eviCore – a team of cancer professionals that, together, perform an upfront prior authorization (PA) review of a customer’s entire oncology treatment regimen. These different entities pool their expertise. Together, they offer a pathway for payers to cover potentially life-altering cures. For individuals covered by a plan with our Embarc solution, such cures are within reach.

Providing a financial safety net
We also provide a financial safety net for the unexpected with our integrated stop-loss protection. This protection ensures quick reimbursement for high-cost drugs. By keeping medical, pharmacy and stop-loss coverage aligned with a single provider, clients may also eliminate the risk of having stop-loss reimbursements denied – since whatever medical and pharmacy cover, stop loss covers too. This is not possible with a stand-alone pharmacy benefit manager (PBM).

Learn More
To learn more about these solutions, please speak with your Cigna sales representative. Ask how we can help you manage your total Specialty spend – now and in the future.

* SaveOnSP copay to be offset by copay assistance, resulting in $0 member cost. Program cost is 25% of the maximized savings – limited drug list and client restrictions apply. Client opt in, must have Exclusive Specialty with zero grace fills, excludes: Insured clients, HSA plans (IRS guidance for first dollar coverage), Private exchange plans, EGWP, IFP, IFP Indemnity plans, and grandfathered plans, standalone pharmacy clients and global. In general to be eligible for coverage a drug must be prescribed by a health care professional, purchased from Accredo, be covered under the pharmacy benefit, and be medically necessary.

  1. Express Scripts Drug Trend Report. 2021.
  2. Cohen, Joshua. At Over $2 Million Zolgensma Is The World’s Most Expensive Therapy, Yet Relatively Cost-Effective. Forbes. Forbes.com. <https://www.forbes.com/sites/joshuacohen/2019/06/05/at-over-2-million-zolgensma-is-the-worlds-most-expensive-therapy-yet-relatively-cost-effective/?sh=347793f145f5>.June 5, 2019. Accessed March 15, 2022.
  3. Accredo Book of Business data. 2021.

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