Embarc Benefit Protection®
Ensuring access to breakthrough gene therapy drugs while protecting plans and members from high costs.
Alleviating the financial burden of high-cost gene therapies
At Evernorth® Health Services, we understand the burden high-cost gene therapies can place on your plan and how their price tags threaten member access. That’s why we created Embarc Benefit Protection®- a program that goes beyond stop-loss coverage to protect plans and the members they serve from the impact of costly gene therapy claims.
Giving members access to potentially life-changing care
We’re aligned, first and always with the people who need care the most. Embarc Benefit Protection offers members with genetic conditions simple, affordable and predictable access to life-changing and potentially curative treatments.
A pathway for affordable access to expensive treatments
Our gene therapy program connects members with best-in-class care using innovative models that drive affordability.
Together with participating plans, we can:
- Improve access to potentially life-changing therapies
- Create cost predictability via a set per-member-per-month (PMPM) fee
- Ensure members receive clinically appropriate, high-quality treatment
Embarc Benefit Protection offers added protection with benefits that stop-loss coverage doesn’t include, such as:
No up-front payments
Unlike stop-loss coverage, with Embarc, plans aren’t responsible for any up-front payments that require a reimbursement. Additionally, a plan’s PMPM fee will not increase when there is a claim.
Predictable costs
Plans pay a set per member per month (PMPM) fee. Then if a member seeks out one of the included gene therapies, members and plans have no out-of-pocket costs for the therapy when Embarc criteria is met*.
Surplus payout eligibility
Even if claims are incurred throughout the year, plans may be eligible for a surplus payout at the end of the year.
How Embarc Benefit Protection works
Once plans join with a PMPM fee, when a member needs a drug that's included in Embarc Benefit Protection, their provider submits a prior authorization request for the gene therapy.
Upon approval, Embarc's case management team will arrange for the provision of the gene therapy drug and ensures the member gets the necessary treatment with no out-of-pocket cost for the therapy.*
The evolution of Embarc Benefit Protection
As the market for gene therapies evolves, we will continue to innovate and find new ways to effectively meet plans and member needs and are excited to announce enhancements to Embarc Benefit Protection effective January 1, 2026:
Broadened access and program portability
that enable plans to join and continue using Embarc Benefit Protection independent of their medical carrier—giving them more control of their gene therapy benefits.
Expanded protection
that combines the cost of the gene therapy drug with medical claims related to the member’s care and gene therapy treatment.
End-to-end case management
that supports members throughout their gene therapy journey.
Utilization management
that ensures a managed cost of care, while providing a seamless member experience.
Proactive management strategy for gene therapy protection
As we continue to evaluate new gene therapies for inclusion in Embarc Benefit Protection, we remain focused on providing payers and their members with appropriate clinical and financial management for gene therapies as they come to market.
Sources
- BioSpace, “U.S. gene therapy market Size to Hit USD 18.50 Billion by 2033”, 2025.
- $913K: Spark Therapeutics Inc. 2025 price of LUXTURNA® therapy in US., $4.25M: BioSpace 2024: published price of LENMELDYTM from the manufacturer
*Members with an HSA must have met the applicable minimum deductible required for a high deductible health plan