Prime Therapeutics launches PreserveRxSM gene therapy financial protection
New offering helps protect health plans, employers from sudden, one-time claims costs while preserving member access to million-dollar curative gene therapies
April 6, 2020
The initial PreserveRx offering will provide financial protection to Blue Cross and/or Blue Shield Plans for five high-cost gene therapies: Luxturna® and Zolgensma®, plus three additional gene therapies that may be approved by the Food and Drug Administration (FDA) this year: valrox, LentiGlobin®, and GT-AADC. PreserveRx is the industry’s only available reinsurance product to include additional coverage for new drugs in the anticipated 2020 pipeline.
Gene therapies are among the newest pharmaceutical innovations to treat and potentially cure disease. It is estimated that by 2025, 10 to 20 new gene therapies will be approved each year.¹’² Today, the drug cost to treat a patient with these gene therapies ranges from $850,000 to $2.1 million, and future therapies (e.g., gene therapy for hemophilia) are estimated to cost $2-3 million.³’4
PreserveRx’s comprehensive offering is two-fold. First, its financial component seeks to provide payer relief associated with one of the covered gene therapies. Second, its clinical services component leverages integrated medical and pharmacy claims data, clinical research and expert analysis to forecast financial impact and potential use for these rare conditions, allowing for a competitively priced product. PreserveRx’s medical policy criteria helps ensure that the right member receives the right treatment. And PreserveRx provides access to savings created through outcomes-based contracts that track and report member outcomes over many years to help ensure the therapy works as claimed.
Prime’s research to identify the number of drug super spenders – members with pharmacy and medical drug therapy claims totaling $250,000 or more annually – provided the foundational insights to inform PreserveRx development.
“We know there’s a small, but growing number of people who have entered the drug ‘super spenders’ category, as they are incurring over $250,000 in pharmacy and medical drug claims due to an illness,” said Patrick Gleason, assistant vice president, health outcomes for Prime. “By 2024, drug super spenders will account for 15% of all drug spend and gene therapies will be an important component. Because of this growing pipeline of expensive drugs and gene therapies, odds are employers will have a drug super spender at some point covered by their benefits. Companies can’t afford to roll the dice any longer or it could take them under – it’s just a matter of when.”
PreserveRx is offered by Prime and reinsured by BCS Insurance Company for Blue Plan payers looking for added protection from the extreme high cost gene therapies. Both Prime and BCS have a longstanding history with Blue Plan insurers.
Health plans will pay a per member per month (PMPM) fee for the coverage of members to be shielded from the ultra-high costs of these one-time gene therapies. Prime anticipates this offering will help provide a seamless experience for providers, pharmacies and members when one of these therapies is needed.
PreserveRx will be expanded in 2021 to include additional FDA approved gene therapies.
- Estimating the Clinical Pipeline of Cell and Gene Therapies and Their Potential Economic Impact on the US Healthcare System. Value in Health Volume 22, Issue 6, June 2019, Pages 621-626.
- Statement from FDA Commissioner Scott Gottlieb, M.D. and Peter Marks, M.D., Ph.D., Director of the Center for Biologics Evaluation and Research on new policies to advance development of safe and effective cell and gene therapies. Food and Drug Administration Jan 15, 2019. https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-and-peter-marks-md-phd-director-center-biologics.
- Feuerstein, A. At $2.1 million, newly approved Novartis gene therapy will be world’s most expensive drug. STAT. May 24, 2019. https://www.statnews.com/2019/05/24/hold-novartis-zolgensma-approval/.
- Hopkins, J. BioMarin Explores Pricing Experimental Gene Therapy at $2 Million to $3 Million. The Wall Street Journal. Jan. 16, 2020. https://www.wsj.com/articles/biomarin-explores-pricing-experimental-gene-therapy-at-2-million-to-3-million-11579190318.
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