AJMC October 28, 2025
Key Takeaways
- Payers acknowledge CGTs’ potential but highlight high costs and uncertain long-term outcomes as significant challenges to adoption.
- Stop-loss coverage, risk pools, and outcomes-based agreements are seen as viable risk management strategies for CGTs.
- Coverage decisions align with clinical trial criteria, but stringent utilization management and prior authorization processes persist.
- CRISPR-based gene therapy coverage is limited by narrow criteria, constrained capacity, and uneven payment model adoption.
Payers cited high upfront costs, long-term uncertainty, and narrow coverage criteria as factors continuing to limit access and reimbursement innovation.
As the number of cell and gene therapies (CGTs) grows, payers acknowledge their potential to transform treatment for rare and chronic diseases. However, they argue that the current reimbursement system is...
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