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