055 Form

Gene Therapies for Sickle Cell Disease – Prior Authorization Request Form for Casgevy ™ (Exagamglogene autotemcel), #055

Medical Policy #050 Gene Therapies for Sickle Cell Disease

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for Casgevy must be submitted.
▪ If the patient does not meet all the criteria listed below, please submit a letter of medical necessity with a request for Clinical Exception (Individual Consideration) explaining why an exception is justified.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations. For out of network providers: Requests should still be faxed to 888-973-0726. Patient Information Patient Name:

Today’s Date: BCBSMA ID#:

Date of Treatment: Date of Birth:

Place of Service: Outpatient  Inpatient 

Distributor:

Physician Information Facility Information Name:

Name:
Address:

Address: Phone #:

Phone #: Fax#:

Fax#: NPI#:

NPI#:

Please check off if the patient has the following diagnosis: Sickle Cell Disease 

Please check off that the patient meets ALL the following criteria:

• 2 -

  1. At least 12 years of age; AND 
  2. Must have a documented genetic test confirming diagnosis of sickle cell disease with genotype of βS/βS, βS/β0, βS/β+; AND (additional genotypes will be considered on an individual consideration basis based on disease severity) 
  3. Have a history of at least 4 severe vaso-occlusive crises in the past 24 months; AND 
  4. Does not have a known 10/10 human leukocyte antigen-matched related donor willing to participate in an allogeneic HSCT; AND 
  5. Has no history of receiving allogenic hematopoietic stem cell transplant; AND 
  6. Does not have advanced liver disease; AND 
  7. Have a negative serologic test for HIV infection; AND 
  8. Have no active bacterial, fungal, parasitic, or viral infection, including active/uncontrolled HBV and HCV; AND 
  9. Have no history of receiving gene therapy or under consideration for treatment with another gene therapy for sickle cell disease 

  HCPCS Codes Code Description C9399 Unclassified drugs or biologicals J3392 Injection, exagamglogene autotemcel, per treatment J3490 Unclassified drugs J3590 Unclassified biologics

  Providers should enter the relevant diagnosis code(s) below: Code Description

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  Providers should enter other relevant code(s) below: Code Description

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