Gene Therapy Risk Protection may help cover therapies and manage financial risk

Gene therapies are single-dose treatments with the potential to create long-term benefits for patients with rare and fatal diseases. As important as these therapies are, they present significant claims risk due to their high cost of treatment (over $2M in some cases) and the unpredictability and rarity of conditions suitable for treatment. 

Starting Jan. 1, 2022, UnitedHealthcare, in partnership with Optum, will offer Gene Therapy Risk Protection – a stop-loss product for gene therapies in which plan sponsors pay a fixed per member per month (PMPM) premium in exchange for claim protection, after the deductible is met. 

This program offers up to 4 therapies to start, all of which are non-oncology and single dose, with a price greater than $750,000. The list of covered therapies will expand in subsequent years as more therapies are launched.

 
Therapy Condition Launch Expected Price*
Luxturna® Inherited retinal disease (IRD) On market $850,000
Zolgensma® Spinal muscular atrophy (SMA) On market $2,125,000
Lenti-D Childhood cerebral adrenoleukodystrophy (CALD) 2021** $2,500,000
NSR-REP1 Choroideremia (CHM) 2021** $1,000,000

*Prices for Luxturna and Zolgensma currently align with actual wholesale acquisition cost (WAC); others are internal estimates.

** Anticipated launch date, pending FDA approval. Contracts will be amended if they do not launch by 2022.

 

Plan sponsors will receive risk analytics and underwriting support, including continued clinical coverage criteria and prior authorization/utilization management (PA/UM) measures through their existing UnitedHealthcare benefits. This integrated approach enables clients to offer coverage for clinically appropriate gene therapies -- and will help drive future medical cost savings for patients provided long-lasting efficacy by gene therapies. 

This product is recommended for self-funded plan sponsors who do not have medical stop-loss in place today and have 5K-40K covered lives. Eligible segments include:

  • OptumRx Direct Health Plan ASO Employer Groups
  • Joint OptumRx – UnitedHealthcare ASO Employer Groups
  • Joint OptumRx – UMR Employer Groups
  • Limited number of TPAs

Please contact your broker or UnitedHealthcare representative for more information.

 

 

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