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.
For protection beyond stop loss coverage, plans need a solution that shields them from high-cost gene therapy claims.
A focus on affordable access to additional expensive treatments
Our pathway connects members with best-in-class care using innovative models that drive affordability.
Together with participating plans, we can:
Improve access to potential life-altering therapies
Connect members with best-in-class providers
Shield plans from price shock of expensive therapies
Provide additional value through an annual surplus refund
Create cost predictability via a set per member per month price (PMPM)
Embarc Benefit Protection offers added protection with benefits that stop loss coverage doesn’t include, such as:
How Embarc Benefit Protection works
Once plans enroll with a PMPM fee, when a member needs a drug that's included in Embarc Benefit 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.*
The evolution 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. Embarc Benefit Protection now includes additional features:
Expanded inclusion of gene therapies
from two in 2020 to 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 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.
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.
Sources
- Cell & Gene, “2024’s Market Outlook for Cell & Gene Therapies”, 2024.
- National Bureau of Economic Research, “Estimating the financial impact of gene therapy in the U.S.”, 2021.
*Members with an HSA must have met the applicable minimum deductible required for a high deductible health plan.