What Is ?

OutcomeRx has developed the Patient Access to Costly and Curative Therapies (PACCT) solution. The PACCT solution is designed to carve out both common and uncommon use cases for the treatment of Spinal Muscular Atrophy (SMA) and Leber Congenital Amaurosis (LCA). PACCT provides first-dollar coverage intended to limit financial exposure for patients, health plans, reinsurance and/or stop-loss organizations while helping to ensure that patients receive timely access to potentially curative therapies.

PACCT reinsurance agreements are issued by US Fire and Ironshore, both A rated US Insurers.

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Covered plans purchasing the PACCT solution will pay a per member/employee per month (PMPM/PEPM) charge to cover the cost of three therapies (up to a predefined limit for the SMA therapies and Luxturna) which adhere to the plan’s medical policy, manufacturer label, and OutcomeRx’s coverage terms: 

Zolgensma® to treat spinal muscular atrophy (SMA)

Registered Trademark of Novartis AG

Spinraza® to treat spinal muscular atrophy (SMA)

 Registered Trademark of Biogen MA Inc.  

Luxturna® to treat leber congenital amaurosis (LCA)

Registered Trademark of Spark Therapeutics, Inc 

The solution will cover the FDA indications for the two SMA therapies specific to Type 1 and 2 for children under 2, who are born after the initial purchase of the PACCT product.

When and Where it is Available:

The PACCT solution will be available in all states for coverage starting on January 1, 2021. PACCT reinsurance agreements are issued by US Fire and Ironshore, both A rated US Insurers. It is currently offered only through reinsurance channels.

Please contact Brooks Wildasin, Business Development at admin@outcomerx.com.

Who Might Need It:

Any risk bearing organization who is financially responsible for these therapies. This includes but is not limited to commercial insurers, regional health plans, managed care organizations, self-funded employers, Health Maintenance Organizations, Medicaid plans.

Pricing Considerations:

The PACCT solution will be priced on a PMPM/PEPM basis and rated on each client’s population and geographic location. For example, a commercial health plan may have a different rating than a state Medicaid plan. Once the rating is calculated, there will be a predictable cost that ensures the plan and its members will be covered for these high-cost but life-changing drugs. Please note the rating charge includes the cost of the therapies only and excludes administration and professional fees.

Coverage is actively designed for the three therapies listed above. OutcomeRx is currently evaluating additional existing high-cost therapies as well as new products coming to the market and will expand its PACCT coverage in the near future.