Protecting Your Health Plan From High-Cost Therapies: A Hemgenix Example
Hemophilia is on the rise. In the 1990s, 1 in 5,000 males received a Hemophilia diagnosis at birth. Today, 1 in 4,334 males receive the diagnosis at birth.
Individuals with Hemophilia have historically had limited treated options, such prophylactic and on-demand clotting factor replacement. This is typically the only treatment option and includes injecting treatment products into the individual’s vein. If the hemophiliac is not dosing prophylactically, any mild or severe injury can cause them to hemorrhage. Not all individuals dose prophylactically as infusions can be time consuming and difficult to fit into a busy schedule, with some hemophiliacs receiving infusions multiple times per week. Side effects from the infusions can occur and can make treatment difficult for some. In addition to this, factor can also be very expensive and the cost can be a barrier to some members.
A New Hemophilia B Treatment Available
On November 22, 2022, the Federal Drug Administration (FDA) approved Hemgenix, a single-dose gene therapy for the treatment of adults with Hemophilia B. For adults with Hemophilia A, gene therapy is currently being researched and is the pipeline with an expected FDA response by March 31, 2023.
Hemgenix is available for adults who:
- Currently use Factor IX prophylaxis therapy, or
- Have current or historical life-threatening bleeding, or
- Have repeated, serious spontaneous bleeding episodes.
Hemgenix is a one-time treatment and is estimated to cost an average of $3.5 million. Despite the initial cost, there are reduced costs associated with long-term treatment of the disease and member benefits including:
- Removing the need for costly prophylactic therapies given over the individuals lifespan
- Treating serious bleeding complications
- Improving the quality of life for the hemophiliac
The average Hemophilia member incurs an average estimate of $500,000 to $1 million in factor costs every year. Clinical trial data suggests that a single dose of Hemgenix will provide members with protection for eight years or potentially longer. This therapy will lead to dramatic trend spikes and stop loss increases, while saving members and pharmacy benefit managers in the long term.
Making the Unaffordable, Affordable
Most of the new gene therapies target rare diseases. However, many common disease states are being researched as well. We are tracking the development of these very costly drugs and developing solutions to help limit the financial impact on your business and your members.
A key part of our solution is our partnership with PayRx™ Solutions. PayRx™ is an on-demand, low-cost risk financing for treatments like Hemgenix. It uses a subscription-based model with customizable risk financing options that help you avoid drastic reimbursement spikes and close gaps in coverage from traditional stop loss insurance. PayRx™ works with both medical and prescription claim administrators to offer risk financing for coverage of Hemgenix or other costly gene therapies in the pipeline. By leveraging data science, purpose-built technology and financial engineering, PayRx™ manages the cost impact of advanced therapies in a unique way that is significantly more affordable, flexible, and provides coverage for not just a few selected therapies but rather a broad range including cell and gene therapies.
With gene therapy advancements offering new solutions for members, pharmacy benefit managers need to be on the cutting edge of financing solutions. At MaxorPlus, our innovative solutions cover the spectrum of high-cost, advanced therapies. We do not tie our clients to a list of specific drugs and we go beyond standard strategies to engage our members. We rely on rebate management, risk financing solutions, utilization management, and our care improvement plan to offer a complete package for high-cost therapies.
Contact MaxorPlus to learn more about our approach to high-cost therapies and how we are improving member outcomes.