Gene Therapy Claims Strain Community Health Plans
Smaller plans must weigh $2 million to $4 million upfront claims against their long-term viability.
Updated on Nov. 3, 2026 in Healthcare
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Carmen Witsken, PharmD, senior manager of pharmacy policy at the Alliance of Community Health Plans, said high upfront costs for cell and gene therapies are straining smaller, community-based health plans. Her remarks came during an Academy of Managed Care Pharmacy Nexus 2026 panel on the next wave of these therapies.
Why it matters
Smaller plans may struggle to absorb one-time claims that can reach $2 million to $4 million while waiting for potential downstream savings. ACHP members must weigh long-term plan viability when making coverage decisions for these therapies.
Upfront claim costs for gene therapies can reach $2 million to $4 million per patient, a figure presented without a stated comparator in the source. The cell and gene therapy pipeline now extends beyond rare diseases into cardiology, metabolic disease, and immunology.
The players
Alliance of Community Health Plans (ACHP)
A trade association representing community-based health plans, which operate on smaller scales than national payers and manage member coverage decisions for these therapies.
Carmen Witsken, PharmD
Senior manager of pharmacy policy at the Alliance of Community Health Plans who addressed cost and claim-approval challenges for cell and gene therapies.
Academy of Managed Care Pharmacy (AMCP)
A professional association for managed care pharmacists that hosts the AMCP Nexus conference where pharmacy policy and payer strategy are discussed.
The details
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 that approval process. Plans and care teams can also agree on patients' goals and expected outcomes through those same relationships and records access. Some national payers maintain their own risk pools, but no system currently exists to finance these therapies nationally.
Timeline
AMCP Nexus 2026: Witsken spoke on the panel 'From Pipeline to Patient: Navigating the Next Wave of Cell & Gene Therapies.'
Market Landscape
The expansion of cell and gene therapies beyond rare diseases into cardiology, metabolic disease, and immunology widens the population of plans that may face high one-time claims. The source does not describe a specific prior deal or regulatory precedent for national financing.
Health plans and their pharmacy teams should factor in the possibility of one-time, high-cost gene therapy claims when forecasting spend and setting coverage policy. Plans may need to prioritize strong relationships with treatment centers and access to electronic health records to speed claim approvals.
The takeaway
Community-based plans should plan for lumpy, high-dollar gene therapy claims that can arrive before any offsetting savings appear. Reviewing how quickly your organization can verify eligibility and coordinate with treatment teams is a practical step worth taking now.
Further reading
For broader context on how payers are handling costly new drugs, see the Healthcare coverage section.
Source note: This article includes information reported by Ajmc.
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Should the U.S. create a national risk pool to help cover expensive gene therapies?
