MedicaidCoverageMedium impact
PT 43-26: Cell and Gene Therapy Access Model for Sickle Cell Disease
Maryland Medicaid·MD · Hematology, Oncology, Pediatrics·Managed Care
Effective date
Jan 1, 2026
We identified it
Jun 18, 2026
Summary
Maryland Medicaid is implementing a new Cell and Gene Therapy Access Model for sickle cell disease effective January 1, 2026, covering two new gene therapy medications (CASGEVY and LYFGENIA) that require prior authorization and must be billed using specific HCPCS codes on UB04 forms only.
Action Required
By January 1, 2026: Billing team must add HCPCS codes J3392 (CASGEVY) and J3394 (LYFGENIA) to billing system with 'payable by invoice' designation. Update system to require prior authorization for both codes. Configure billing to only accept UB04 claims for these medications - block CMS1500 submissions. Train staff that these therapies can only be administered at authorized treatment centers (Children's National Medical Center or University of Maryland Medical Center). Claims without proper authorization or submitted on wrong form will be denied.