Cell, Gene Therapy Costs Strain Smaller, Community-Based Health Plans

As the cell and gene therapy pipeline expands beyond rare diseases, the high upfront costs of these treatments are straining health plans’ ability to cover them, particularly smaller, community-based plans, according to Carmen Witsken, PharmD, senior manager of pharmacy policy at the Alliance of Community Health Plans (ACHP).

Witsken, a panelist for the Academy of Managed Care Pharmacy Nexus 2026 session “From Pipeline to Patient: Navigating the Next Wave of Cell & Gene Therapies,” told The American Journal of Managed Care^® at the meeting that although rare diseases and oncology have historically dominated the field, the pipeline now includes more therapies for less rare conditions in cardiology, metabolic disease, and immunology.

That shift adds to financial pressures, as gene therapies can carry upfront claim costs of $2 million to $4 million. Witsken explained that plans may find it easier to finance lower-cost therapies with quicker outcomes, but smaller, community-based plans may struggle to absorb a one-time, high-cost claim while waiting for potential savings. As a result, patient access may hinge on whether a given plan can manage that expense, she said.

Witsken identified plans’ relationships with treatment teams and centers as the biggest barrier to claim approval. Access to electronic health records and established relationships with therapy teams can help expedite the process and ensure that plans and care teams agree on patients’ goals and expected outcomes.

When long-term benefits are uncertain, many plans seek out risk pools, although the private market lacks an affordable option, Witsken noted. Coverage decisions require weighing patient needs and potential benefits against a plan’s financial sustainability. She explained, for example, that ACHP members do try to get to “yes,” but they must also consider long-term plan viability. Although some national payers maintain their own risk pools, no system currently exists to finance these therapies nationally, Witsken said.

“…a risk pool that can capture all lives across the United States, no matter line of business or health plan, would be the most viable and helpful resource for making sure that…the risk of these therapies is spread evenly across plans but also that patients aren’t limited to these therapies based [on] the health plan that they have,” she concluded.