MedicaidCoverageHigh impact
Coverage for Casgevy (J3392) and Lyfgenia (J3394) for the Sickle Cell Gene Therapy Model
Arkansas Medicaid·AR · Hematology, Pharmacy, Pediatrics·Pharmacy
Effective date
Jan 1, 2026
We identified it
Mar 24, 2026
Summary
Arkansas Medicaid adds new coverage for Casgevy (J3392) and Lyfgenia (J3394) gene therapies for sickle cell disease, effective January 1, 2026. Hospitals must bill these drugs on separate outpatient claims with specific modifiers (U1, U7, UA) even when administered during inpatient stays, and prior authorization is required. 340B providers must include additional modifiers, and members are limited to one lifetime administration of either drug.
Action Required
By January 1, 2026: Billing team must implement the following changes: (1) Update billing software to recognize J3392 and J3394 as separately billable outpatient claims even during inpatient stays; (2) Require modifiers U1, U7, and UA on all J3392 and J3394 claims (U1 mandatory for all, U7 and UA only for 340B providers); (3) Establish workflow to submit prior authorization to Arkansas Foundation for Medical Care (AFMC) at 1-800-426-2234 before service delivery; (4) Configure system to include NDC codes on all claims for these drugs; (5) Update billing to submit outpatient CMS-1450 claims on paper to Utilization Review with drug invoice attached; (6) Create edit to flag and prevent billing either drug more than once per member lifetime; (7) Add verification step to confirm Medicaid is primary insurance for all members receiving these drugs; (8) Route PASSE member claims directly to Medicaid Fee-For-Service. Providers must reference Hospital Provider Manual Section 272.104 for additional guidance. Failure to comply with billing requirements will result in claim denials and improper reimbursement.