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NEW TREATMENT METHODS: GENE THERAPY AND IMMUNOTHERAPY

Gene therapy Learn more about third-party links is a new treatment that has been approved to treat many rare health conditions that often don’t have a cure. Instead of drugs, surgery or other treatments, gene therapy uses genes to treat or prevent disease. Most often, gene therapy works by inserting a healthy copy of a bad gene into the patient’s cells. This method is a revolutionary shift in medical care as it targets disease in a more direct and personal way.

At Blue Cross and Blue Shield of Montana (BCBSMT), we want our members to have access to medical breakthroughs like gene therapy and immunotherapy. In the past year, we’ve seen the first 3 gene therapy treatments approved by the Food and Drug Administration (FDA) and a new immunotherapy treatment.

Luxturna is the first true gene therapy approved by the FDA. It targets a gene disorder that causes blindness. The doctor injects the eye with a virus with a working copy of the bad gene. This could bring back a patient’s eyesight.

Before Luxturna, the FDA approved Kymriah and Yescarta to treat rare forms of lymphoma. These are called Chimeric Antigen Receptor (CAR-T) drugs. They are made from a patient’s immune cells that have been changed so they attack the cancer.

As of Jun. 1, 2018, BCBSMT medical policies have been established with coverage criteria for Kymriah, Yescarta and separately, Luxturna.

If you’re a BCBSMT member, talk with your doctor about treatment options. If you have questions about your coverage, call the Customer Service number on the back of your member ID card.

OUR ROLE

As the industry continues to expand the realm of possible treatments for our members, we at BCBSMT are committed to:

  • Evaluate effectiveness
  • Promote transparency, access and affordability
  • Advocate for meaningful policy

Evaluate Effectiveness

As with any treatment, we’re doing all we can to provide members with access to quality care. As new treatments emerge, we must evaluate whether they’re safe and effective.

We look at:

  • FDA approval: The FDA reviews the results from drug makers’ clinical tests to decide whether new drugs and certain biologic therapies are safe and effective for their planned use.
  • Ongoing clinical trials: We continuously review the most recent scientific studies of a treatment’s effectiveness as more data is released.
  • Expert opinion: Our medical team works with doctors and researchers to review how well the drug works and treatment choices that promote quality, cost-effective outcomes.

Promote Transparency, Access and Affordability

BCBSMT has the clinical and business expertise and contacts with providers so members who need these treatments get the full value

Transparency

We believe our role in the early stages of gene therapy should focus on how industry partners are testing, pricing and contracting with providers. Fostering a national, industrywide dialogue is key.

By working with our pharmacy benefit manager, Prime Therapeutics, we can better manage medical and drug benefits. Gene therapy, like specialty drugs or infusions, can come with 6- or 7-figure prices. They’re often paid for using the medical benefit because they need to be given by a doctor.

Access

BCBSMT has updated our plans with coverage criteria on some gene therapies for the small number of people who may need them. We’re working closely with hospitals and other treatment facilities to provide access and help members get the full value of the treatment.

By including clinics that offer gene therapies to our list of providers, members access the care they need at a lower cost site of care, which may lead to improved health outcomes.

There are only a few places that provide gene therapy today. We’ve signed contracts with many of them, but they aren’t in everyone’s hometown. Members may have to travel out of state for treatment. Depending on their type of health plan, members should call the Customer Service number on the back of the member ID card to confirm where they can go to receive care.

Affordability

We work with drug makers and others to determine appropriate reimbursement rates for treatments covered by our plans.

Gene therapies are covered under the medical benefit rather than the pharmacy benefit because they must be given in a medical setting. When CAR-T therapies are used, members have lengthy hospital stays and routine monitoring, which add large costs to the total treatment.

When finding ways to lower these costs, we think about all the care that is provided by hospitals and treatment facilities. We negotiate not only the price of the drug, but the cost for all related medical provider services.

Advocating for Meaningful Policy

We will keep promoting common-sense cost transparency by working with lawmakers, regulators and industry partners to advocate for lower costs and more access to this revolutionary type of care.

Third-Party Resources

Making the Health Care System Work: A New Kind of Drug May Demand New Ways to Pay Learn more about third-party links

U.S. National Library of Medicine: What is Gene Therapy? Learn more about third-party links

American Cancer Society: Cancer Immunotherapy Learn more about third-party links