MedicaidPrior AuthMedium impact
ForwardHealth Update 2025-37: Changes for Casgevy and Lyfgenia and Other Polices in the New Cell and Gene Therapy Access Model for Members With Sickle Cell Disease
Wisconsin ForwardHealth·WI · Hematology, Oncology·Provider Update
Effective date
Jan 1, 2026
We identified it
Jun 18, 2026
Summary
Wisconsin ForwardHealth (BadgerCare Plus/Medicaid) is implementing the Cell and Gene Therapy Access Model for sickle cell disease treatments Casgevy and Lyfgenia, with revised clinical criteria and prior authorization requirements. Members participating in the model will be permanently exempted from HMO enrollment requirements.
Action Required
By January 1, 2026: Billing teams treating sickle cell disease patients must verify updated prior authorization requirements for Casgevy and Lyfgenia through ForwardHealth. For Casgevy, ensure pharmacy claims include member's diagnosis code and date of service matches infusion date. Contact DHSOrphanDrugs@dhs.wisconsin.gov for specific billing questions. HMOs must process exemption requests for CGT Access Model participants with approved PA documentation.