Changes for Casgevy and Lyfgenia and Other Polices in the New Cell and Gene Therapy Access Model for Members With Sickle Cell Disease

By December 31, 2025: (1) Billing team must configure the billing system to require clinical prior authorization for Casgevy and Lyfgenia before claims are submitted. (2) Update pharmacy billing system to mandate that diagnosis codes are included on all Casgevy and Lyfgenia pharmacy claims, with the date of service set to the member's infusion date—not the prescription date or dispensing date. (3) Create internal guidance document clarifying that only BadgerCare Plus and Medicaid members (excluding CHIP) with documented SCD diagnosis and infusions on/after January 1, 2026 qualify for the CGT Access Model. (4) Notify all providers and treatment centers submitting Casgevy claims of new requirements and direct them to ForwardHealth Portal Pharmacy Resources page for high-cost drug billing details. (5) Establish process to coordinate with managed care organizations regarding member managed care exemption requests after approved prior authorization and scheduled infusion date. Claims submitted without required prior authorization or with incorrect date of service will be denied. Contact DHSOrphanDrugs@dhs.wisconsin.gov for coverage and billing questions on these high-cost drugs.