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Texas Medicaid Cell & Gene Therapy Access Model for Sickle Cell Disease

Date: 10/12/26

Superior HealthPlan would like to inform providers about the Centers for Medicare & Medicaid Services (CMS) Cell & Gene Therapy (CGT) Access Model for members with Sickle Cell Disease (SCD).

Effective September 2025, Texas Medicaid began participating in the CMS CGT Access Model, which is designed to improve access to gene therapy treatments for individuals living with Sickle Cell Disease, including CASGEVY™ and LYFGENIA™.

For Texas Superior Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP members, both products require clinical prior authorization (PA) under the medical, clinician-administered drug (CAD) benefit using their respective HCPCS codes:

  • CASGEVY™ (J3392)
  • LYFGENIA™ (J3394)

Superior aligns its prior authorization review process for CASGEVY and LYFGENIA with the criteria and guidance outlined in the Texas Medicaid Provider Procedures Manual (TMPPM). For additional information, please refer to the TMPPM.

These therapies must be administered at qualified treatment centers and are subject to Superior prior authorization requirements.

Provider Reminders

  • Members must meet applicable clinical criteria before treatment approval.
  • Prior authorization is required.
  • Providers should follow all applicable Texas Medicaid and Superior billing requirements.
  • Gene therapy administration must occur through qualified treatment centers authorized to provide these services.
  • Related services should be coordinated according to established treatment protocols and member care needs.

Questions?

For questions regarding prior authorization requests for CASGEVY or LYFGENIA, please contact the Superior Pharmacy team at: