Sickle Cell Disease Therapy Coverage Guidance

Date: January 25, 2025

Attention: Hematologists

Call to action: Texas Children’s Health Plan (TCHP) would like to remind providers about the sickle cell disease therapies covered benefit for Texas Medicaid clients. To support this benefit, TCHP and all MCOs must establish a patient care plan for the member. The care plan should consider any transportation or housing needs related to traveling to a qualified treatment centers (QTC). Also, please keep in mind each QTC may have different approaches to managing the treatment process. Also included later in this communication is an important update to the prior authorization requirements for TCHP.

Background information: Casgevy (procedure code J3392) is indicated for the treatment of clients 12 years and older with Sickle cell disease with recurrent vaso-occlusive crises or transfusion-dependent ß-thalassemia. Lyfgenia (procedure code J3394) is indicated for the treatment of clients 12 years of age or older with sickle cell disease and a history of vaso-occlusive events. These gene therapies are administered in QTC for clients who meet the prior authorization criteria.

How this impacts providers: 

Prior authorization update information:

Casgevy, J3392 and Lyfgenia, J3394 prior authorization requirement, age and diagnosis restrictions:

• Casgevy (procedure code J3392) is indicated for the treatment of clients 12 years and older with Sickle cell disease with recurrent vaso-occlusive crises or transfusion-dependent ß-thalassemia
• Lyfgenia (procedure code J3394) is indicated for the treatment of clients 12 years of age or older with sickle cell disease and a history of vaso-occlusive events 

Treatment consists of six phases:

1. Patient Identification and Evaluation

2. Pre-Mobilization

3. Mobilization and Collection

4. Product Manufacturing and Quality

5. Conditioning, Administration, and Engraftment

6. Long-term follow-up

Resources:

• An example of a treatment journey with a timeline can be found at Improved Access to Gene Therapy for Sickle Cell Disease: Maya’s Care Journey (cms.gov).
• Lyfgenia: Steps to Treatment
• Casgevy: A Guide to Your Treatment Journey

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org. 

For access to all provider alerts: https://www.texaschildrenshealthplan.org/providers/provider-news/provider-alerts.