Gene therapy policy

ZolgensmaGene therapy is an exciting new medical technique that inserts genes into a person’s cells to treat or prevent disease. While gene therapy can potentially cure a wide range of diseases caused by genetic mutations, it comes with a high price tag.

The FDA recently approved the drug Zolgensma®, gene therapy for pediatric patients with spinal muscular atrophy (SMA). A single dose of Zolgensma, which may cure this fatal disease, costs more than $2 million.

Policy and processes

MagnaCare has put a policy and process in place establishing strict controls about when Zolgensma is approved for payment.

  1. The most important of these controls is whether your benefit plan covers gene therapies.
  2. Second is whether the patient is eligible for treatment from a clinical point of view. (You may request a copy of our policy laying out how we determine eligibility.)
  3. Third, we have established a drug acquisition program to control the contract cost of the drug when it is supplied.
  4. Fourth, when we administer claims and benefits, we have system controls in place that block payments without explicit approval from you and our Chief Medical Officer.

Next steps

  • Your Account Manager will be in touch with you to review your benefit plan to confirm coverage or non-coverage.
  • If your health plan covers gene therapy:
    • You need to plan how you will cover the cost should one of your members meet criteria for approval. Approaches to consider include stop-loss insurance and pay-over-time programs.
    • Speak with your Account Manager about our drug acquisition program, or one that may be available to you through your specialty pharmacy vendor.

We encourage you to share this information with relevant members of your team, and to talk to your MagnaCare Account Manager about the options available to you.

As additional costly gene therapies emerge, it is important to update your Summary Plan Description to indicate whether and how gene therapy will be covered. As always, your Account Manager is available to you to provide guidance.

Information about LabCorp and Quest Diagnostics data breach

Two of the country’s largest lab providers, LabCorp and Quest Diagnostics, discovered a data breach that occurred at a third-party vendor they both use for billing and collections. This data breach occurred between August 1, 2018 and March 30, 2019. Both LabCorp and Quest have both stated that the breach is limited to members who were referred to a third-party debt collection vendor due to unpaid bills.

The labs are unable to inform affected payors regarding which or how many of their members were impacted by the data breach. If any of your members were affected, they will receive or may have already received notification letters from LabCorp and/or Quest Diagnostics outlining what they can do to protect their identity.

According to the information we received from the labs, the breach included identification and contact information such as name, date of birth, address, and phone number; and payment information such as bank account number, payor information, and diagnosis codes. Credit card information and test results were not included in the breach.

We are not aware of any misuse of patient information related to this incident.

Further details may be obtained from LabCorp and Quest Diagnostics.



MagnaCare Partners with MLMIC to Offer Medical Liability Insurance Program Offering Significant Savings for Qualified NY Participating Providers

MLMIC logoNEW YORK, July 01, 2019 – MagnaCare, a leader in health plan management, network rental, medical management and casualty solutions, is partnering with MLMIC Insurance Company on a new discount program that offers our New York providers the potential to save significantly through the association with MLMIC on their medical liability insurance premiums.

Through the partnership with MLMIC, part of the Berkshire Hathaway family of companies and the largest writer of medical professional liability insurance in New York, qualifying MagnaCare participating providers receive a discount of up to 12% when they participate in joint legal defense and a risk management course. Our providers may also qualify for additional discounts, including MLMIC’s claims free discount (7.5% or 12%), a no-consent option discount (5%) and an annual prepay discount (2%).

MagnaCare exclusively endorses MLMIC to offer these discounts to its qualifying participating providers, who also gain access to MLMIC’s, New York-focused benefits at no extra charge, including:

  • MLMIC Risk Protect: New York-specific risk management services designed to help manage risk, reduce exposure and prevent adverse outcomes
  • MLMIC Legal 24/7: A direct connection to experienced attorneys who are exclusively dedicated to New York healthcare law
  • MLMIC Analytics: Analysis and reporting based on 40+ years of New York claims data uncovering key trends and potential risks
  • MLMIC CME+: A growing library of cutting-edge, online CME programs

“We’re proud to bring these savings to MagnaCare’s New York participating providers and to offer them access to MLMIC’s valuable benefits and locally-based services,” says Rondi Rabuse, President of Network. “I’m always looking for ways to bring more value to our providers, and MLMIC is exclusively committed to New York medical professionals.”

“MLMIC’s New York focus – a commitment that spans over four decades – means we can offer MagnaCare participating providers in the state the kind of expertise they need. MLMIC understands what it means to be a provider in cities and communities across New York,” says MLMIC Chief Medical Officer John Lombardo, M.D. “In addition, through our relationship with Berkshire Hathaway, Inc., MLMIC has access to greater resources for physicians and other healthcare providers than ever before.”

This Program is effective immediately (July 1, 2019), and MLMIC offers tail and nose coverage options so providers can avoid gaps in coverage when switching to the Program. In addition, to make the transition as easy as possible for providers, MLMIC provides one-on-one assistance with paperwork and related tasks.

For additional information, including a customized quote and how to participate in the Program, please call (888) 449-6411 or visit

About MagnaCare

For more than 25 years, MagnaCare, a division of Brighton Health Plan Solutions, has helped organizations in New York, New Jersey and Connecticut take control of their healthcare costs and give their members access to high value care. MagnaCare has served self-insured employers and health, workers’ compensation and no fault payers, including commercial insurers, TPAs, government entities and labor markets. MagnaCare offers access to a broad proprietary provider network, micro-networks, predictive modeling analyses, member outreach programs and integrated solutions that include full benefit plan management services. Services include claims adjudication, eligibility management, client/customer service and a full suite of products.


MLMIC, formed in response to the medical professional liability insurance crisis of the late 1970s, has been a leader in the medical malpractice insurance industry for over 40 years. Today, MLMIC is not only the largest writer of medical professional liability insurance in the State of New York, but is also one of the largest companies of its kind in the nation. MLMIC insures more than 13,000 providers, 3,000 dentists, dozens of hospitals and thousands of other healthcare professionals and facilities and is proudly endorsed by more than 70 state, county medical and specialty societies. In 2018, MLMIC was acquired by National Indemnity, a Berkshire Hathaway company, launching a new era as New York’s premier medical professional liability carrier. MLMIC has more than 350 employees and field reps positioned throughout New York – local professionals ready to meet one-on-one with policyholders, review cases, coordinate with examiners and defense counsel, and more.