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 the 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.

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