Medicaid Practitioner Administered Drugs Update: CGT

TO: All Medicaid Providers

Effective January 1, 2026, the New York State (NYS) Department of Health has applied to participate in the federal Centers for Medicare and Medicaid Services (CMS) Cell and Gene Therapy (CGT) Access model. The initial focus of the model is on gene therapies for people living with sickle cell disease, inclusive of Casgevy™ (exagamglogene autotemcel) and Lyfgenia® (lovotibeglogene autotemcel).

Based on NYS Medicaid billing and reimbursement guidelines:

• For Drug Coverage and Reimbursement Criteria:
  • Casgevy™ (HCPCS code J3392) and Lyfgenia® (HCPCS code J3394).
    • Providers should bill Medicaid NYRx directly, for Casgevy and Lyfgenia.
• Provider Administered Drug – Billing and Reimbursement Criteria:
  • MetroPlus Health will allow coverage and reimbursement of claims billed with the drug administration CPT codes as follows:
    • For Lyfegnia: 38241, 96365, 96413
    • For Casgevy: 38241, 96374, 96376, 96409
• Prior Authorization Required
  • Providers should follow the Prior Authorization rules and criteria for provision of these drug administration services.

For more information, please refer to the “CGT Access Model Frequently asked Questions” web page: https://www.cms.gov/cgt-access-model-frequently-asked-questions.

If you have any questions regarding this memo, please contact MetroPlusHealth at [email protected].

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