New Gene Therapies Spark Transformative Healthcare Changes

It’s estimated that genetic and rare diseases affect about 1 in 10 people in the United States. While these treatments herald a new era in healthcare innovation, they also come with significant financial implications. By 2032, the cost of gene therapies is expected to reach up to $35-40B in the U.S., and there are more than 25 new gene therapies expected to receive FDA approval through 2026. Considering these escalating costs, insurers and employers are adopting strategies to manage the expense of gene therapies, which include setting rules for who can receive such treatments and introducing payment options to help with therapy costs.

Experts are also recognizing the value of treating the whole person, not just the disease. This is why insurers like Anthem are taking a holistic approach to treating rare genetic conditions by bringing together health services, medical management, healthcare data, and specialty pharmacy expertise.

Anthem’s Gene Therapy Solution works as an extension of its stop loss products to protect self-insured employers from unknown financial risk, while also providing robust care management for employees and their family members with rare and complex conditions. In addition to covering both treatments and medical costs, we will not impose exclusions or lasers on future gene therapies that are covered by the Anthem Gene Therapy Solution.

Anthem also uses a comprehensive blend of clinical and contractual strategies to manage costs for employers. This includes utilization management criteria to help guide essential treatments and reduce unnecessary costs, strategic provider contracting for drug and service costs, and agreements with pharmaceutical companies for rebates or payments for unsuccessful treatments.

A Growing Gene Therapy Pipeline

In addition to the seven gene therapies already covered by Anthem’s Gene Therapy Solution, there are four new therapies approved for 2025 coverage:

• Lyfgenia^TM is a one-time gene therapy used to treat sickle cell disease in individuals over the age of 12 with a history of vaso-occlusive events (VOEs).
  
  
• Lenmeldy^TM is a one-time gene therapy used to treat early onset metachromatic leukodystrophy (MLD) in pre-symptomatic individuals that may yield a lasting preservation of cognition and motor function.
  
  
• Casgevy^TM is a one-time gene therapy used to treat sickle cell disease in individuals over the age of 12 years with a history of VOEs and individuals with beta thalassemia who need regular blood transfusions.
  
  
• Beqvez^TM is a one-time gene therapy used to treat individuals with moderate to severe hemophilia B who are receiving routine prophylaxis, have a current life-threatening bleed, a history of life-threatening bleeds, or repeated serious spontaneous bleeds.

Connecting Employees To Transformative Care

As more gene therapies become available, Anthem’s pharmacy benefits manager, CarelonRx, will continue to monitor the drug and biologic pipeline, evaluating the potential efficacy of new treatments and making certain they are medically necessary according to medical policy.

As gene therapy advances, it's vital for employers to consider health coverage plans and cost management strategies that connect employees to these life-changing holistic treatments. Employers can foster healthcare innovation and enhance their employees' well-being, while also protecting their financial interests, by integrating medical and pharmacy benefits and collaborating with a dependable health partner dedicated to improving lives.