EMBARC BENEFIT PROTECTION^®

Ensuring access to breakthrough gene therapy drugs while protecting plans and members from high costs.

Affordable access to gene therapies

We are Evernorth^®, the health services company creating a future without compromise. We understand the immense burden that high-cost gene therapies often place on your plan and the members you serve.

We’re aligned, first and always with the people who need care the most, which is why we created Embarc Benefit Protection, a comprehensive program that offers patients with genetic conditions simple, affordable and predictable access to life-changing and potentially curative treatments.

A 4x increase in gene and cell therapy approvals is expected for 2024, rising to a 10x increase by 2027.¹

However, the high cost of these medications threaten access to those who may benefit most from these revolutionary therapies. For protection beyond stop loss coverage, plans need a solution that shields them from high-cost gene therapy claims.

1. Cell & Gene, “2024’s Market Outlook for Cell & Gene Therapies”, 2024.

$25B+

annual cost of gene therapies by the end of 2034 with more than 1 million patients receiving treatment.²

2. National Bureau of Economic Research, “Estimating the financial impact of gene therapy in the U.S.”, 2021.

Improve access

to lifesaving and potentially life-altering therapies for members

Create cost predictability

via a set per member per month (PMPM) price. Once plans have protected their member population through Embarc Benefit Protection, if a patient seeks one of the included gene therapies, they won’t pay any out-of-pocket medication costs*

*Members with an HSA must have met the applicable minimum deductible required for a high deductible health plan

Shield plans

from the price shock of suddenly paying for million-dollar therapies

Provide additional value

through an annual surplus refund that may be available based on overall program claims paid vs. anticipated utilization

Connect members

with best-in-class providers and support them on their health care journey

Protection beyond stop loss

Stop loss coverage acts like an insurance policy for your plan offering valuable protection against high-dollar claims. However, there are often high deductibles that need to be met and price increases that are applied to premiums when claims are filed.

Members and plans have no out-of-pocket costs for the therapy when Embarc criteria is met.*

For one low PMPM rate, Embarc covers high-cost gene therapies that are sometimes lasered out of stop loss coverage.

With Embarc, plans aren’t responsible for any up-front payments that require a reimbursement from the stop loss carrier. Unlike stop loss coverage, a plan’s PMPM rate does not increase when there is a claim.

Even if claims are incurred throughout the year, plans may be eligible for a surplus payout at the end of the year.

Once plans enroll with a PMPM fee, when a member needs a drug that's included in Embarc Benefits Protection, their provider submits a request for the drug through their existing prior authorization process. Upon approval, our exclusive in-network provider for gene therapy drugs, EviCore, arranges for the provision of the gene therapy drug and ensures the member gets the necessary treatment with no out-of-pocket cost for the medication.*

*Members with an HSA must have met the applicable minimum deductible required for a high deductible health plan

The future of Embarc Benefit Protection

As the market for gene therapies evolves, we will continue to explore new ways to effectively meet plan and member needs. Starting on January 1, 2025, Embarc Benefit Protection will include additional features:

Expanded inclusion of gene therapies from two in 2020 to an estimated nine by the end of 2024, with an anticipated 13-15 covered therapies by the end of 2025. We will continue to evaluate new gene therapies for inclusion as they emerge and receive FDA approval.

Expanded condition support for prevalent indications like hemophilia and sickle cell, increasing the likelihood that a plan will have a member needing coverage for high-dollar drugs.

Removal of contractual limitations on select gene therapies* previously with “new-to-plan” restrictions, expanding member access to gene therapies regardless of when plans enroll.

Behavioral health services provided by uniquely trained therapists who specialize in member and caregiver support for complex genetic conditions and treatments.

To support this exciting expansion of benefits, the PMPM fee will be adjusted to $1.25.

An estimated nine therapies will be included by the end of 2024 with 13-15 expected by the end of 2025.

With the groundbreaking number of FDA approvals expected, it’s important to ensure your plan is protected from expensive claims that could affect your bottom line. Even as the cost of these therapies continue to rise—averaging $850K in 2020 to $4M in 2024— Embarc Benefit Protection guards your plan from the high cost of gene therapy.

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.

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