Cell and gene therapies carry price tags that can exceed $2 million to $4 million per treatment, yet the actual cost burden on employer health plans has remained narrow, according to analysis from Lockton.
Data from the brokerage firm’s SAGE Intelligence Platform show that gene therapy cases occur at just 6.25 per million lives annually among its clients, while cell therapy cases occur at 15 per million lives. Incidence rates at that level have not produced widespread plan-level cost pressure.
Lockton attributes that limited exposure not to low prices, but to a set of practical constraints that have prevented clinically eligible patients from reaching treatment.
Why Utilization Has Stayed Low
The barriers keeping utilization in check are structural, not simply financial. According to Lockton, access to cell and gene therapies is restricted by a limited number of qualified treatment centers, strict clinical eligibility and prior authorization requirements, complex manufacturing and scheduling timelines, and care delivery models concentrated in major health systems.
Even patients who clear clinical eligibility thresholds face additional obstacles, including extended post-treatment monitoring periods, the need to remain in proximity to specialized centers, and demands for significant caregiver support.
Lockton draws a distinction between the two categories of therapy from a risk management standpoint. Cell therapies, which are largely oncology-driven, carry higher utilization than early projections suggested and present a larger addressable market given cancer prevalence. The analysis identifies proactive management as a requirement for this category.
Gene therapies, by contrast, treat rare or previously untreatable conditions, and utilization has run below early projections, meaning the risk is severe when it occurs, but the probability remains low. Lockton’s analysis notes that operational and medical costs for cell therapies often exceed the price of the drug itself, while product cost dominates for gene therapies.
The Conditions That Could Change the Picture
Lockton characterizes the current environment as a temporary reprieve rather than a permanent baseline. Two developments are identified as most likely to erode today’s constraints. First, cell therapies are moving from inpatient hospital settings into outpatient delivery models. The shift expands treatment capacity, reduces logistical barriers, and is expected to bring more clinically eligible patients to treatment over time.
Second, and potentially more consequential for employer plans, the pipeline of new therapies is expanding heavily into autoimmune disease. With more than 100 late-stage autoimmune therapies in development, Lockton notes that autoimmune conditions are more prevalent than the cancers and rare diseases currently driving utilization, are concentrated in working-age populations, and are already associated with significant specialty drug spending.
The article concludes that this category has the potential to shift cell and gene therapies from rare events to “repeatable exposure within employer populations.”
What Employers Are Being Advised to Examine
Lockton is clear that the current moment does not call for a fundamental redesign of employer health plans, but argues that preparation is warranted given the trajectory. The analysis recommends that employers focus on several areas when approaching coverage decisions: establishing clear eligibility and prior authorization standards, aligning on site-of-care and center-of-excellence requirements, coordinating carefully with stop-loss coverage, and maintaining strong plan governance and documentation.
The article also flags compliance considerations that should inform how employers structure coverage. These include nondiscrimination requirements under the Americans with Disabilities Act and HIPAA, plan document drafting obligations, and employee notice and disclosure requirements under ERISA.
Lockton warns that exclusions for these therapies may carry meaningful reputational consequences, particularly where treatments are FDA-approved and affect vulnerable populations.
Obtain the full analysis here . &