MedicaidAdministrativeMedium impact
Cell Gene Therapy (CGT) Access Model
Illinois Medicaid - HFS·IL · Hematology, Oncology·Provider Notice
Effective date
Jan 1, 2026
We identified it
Jun 16, 2026
Summary
Illinois Medicaid is participating in a new Cell and Gene Therapy Access Model effective January 1, 2026, covering specific drugs for Sickle Cell Disease (Casgevy and Lyfgenia). Hospital providers must follow special billing procedures, submitting two separate claims and meeting specific provider requirements including manufacturer agreements and CIBMTR membership.
Action Required
Before January 1, 2026: Hospital providers administering Casgevy (J3392) or Lyfgenia (J3394) must obtain manufacturer agreements and become active CIBMTR members. Billing team must update procedures to submit two separate claims: 837I for hospital stay (excluding CGT drug cost) and 837P for CGT drug using hospital's 40X number at Actual Acquisition Cost. Review prior authorization criteria at https://ilpriorauth.com/pages/14.