Gene Therapy Costs Strain Community Health Plans
Carmen Witsken of the Alliance of Community Health Plans describes how high upfront cell and gene therapy claims burden smaller insurers.
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 strain smaller, community-based health plans. She spoke as a panelist at the Academy of Managed Care Pharmacy Nexus 2026 session 'From Pipeline to Patient: Navigating the Next Wave of Cell & Gene Therapies.'
Why it matters
The cell and gene therapy pipeline now includes treatments for more common conditions in cardiology, metabolic disease, and immunology, widening the number of patients and plans affected. Smaller plans may struggle to absorb a one-time, high-cost claim while waiting for potential savings.
Gene therapies can carry upfront claim costs of $2 million to $4 million, according to remarks made at the AMCP Nexus 2026 session. No national financing system currently exists to cover these therapies, and the session did not describe a planned solution.
The players
Carmen Witsken, PharmD
Senior manager of pharmacy policy at the Alliance of Community Health Plans, a pharmacist who advises member plans on drug coverage policy.
Alliance of Community Health Plans
A national association representing community-based health plans, which must weigh long-term plan viability when making coverage decisions.
Academy of Managed Care Pharmacy
A professional organization for pharmacists working in managed care, which hosted the Nexus 2026 conference where the session took place.
The details
Witsken identified plans' relationships with treatment teams and treatment centers as the biggest barrier to claim approval. Access to electronic health records and established relationships with therapy teams can help expedite the approval process, and some national payers maintain their own risk pools.
Timeline
AMCP Nexus 2026: Witsken spoke as a panelist at the conference session.
Market Landscape
The shift toward one-time, high-cost curative gene therapies is pushing insurers to rethink how they pay for care. Smaller plans without their own risk pools face a different financing challenge than national payers that can spread costs across larger populations.
Patients needing gene therapies may face coverage decisions shaped by their health plan's size and financial reserves. Plans that cannot absorb one-time claims of several million dollars may limit access or change how they approve these treatments.
The takeaway
Coverage for expensive gene therapies depends heavily on whether a health plan has the reserves and relationships to absorb one-time costs. Patients and families should ask their plans how claims for these treatments are reviewed and approved.
Further reading
For more on the financing pressures facing insurers, see Healthcare coverage.
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?
