Cell and Gene Therapy Access Model and Coverage
| Date: | June 17, 2026 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Qualified Treatment Centers (QTC’s) and Authorized Treatment Centers (ATC’s) |
| Type: | Regulatory |
| Subject: | Cell and Gene Therapy Access Model and Coverage |
| Business: | Medi-Cal Managed Care |
Background on Cell and Gene Therapy Coverage
In March of 2025, the Department of Health Care Services (DHCS) received approval from Centers for Medicare and Medicaid Services (CMS) to participate in the federal Cell and Gene Therapy (CGT) Access Model for Medi-Cal. On May 30, 2025, CMS and DHCS signed the CGT Access Model Agreement. The Model aims to improve and streamline access to two life-changing CGT medications for Medi-Cal members. In alignment with CMS requirements, the initial focus of the CGT Access Model will be on providing coverage for cell and gene therapies specifically approved for the treatment of Sickle Cell Disease (SCD). This includes the following therapies:
- CASGEVY by Vertex Pharmaceuticals, Inc.
- LYFGENIA by bluebird bio, Inc.
Under the Model, these medications are carved out from Managed Care Plan (MCP) coverage and covered by Fee-For-Service (FFS), while MCPs remain responsible for all associated outpatient or inpatient medical services and non-medical ancillary services that support members through their SCD CGT treatments, such as transportation.
CGT Access Model Eligibility
To be eligible for Medi-Cal’s CGT Access Model, Medi-Cal members must meet all of the following criteria:
- Have a documented medical diagnosis of SCD
- Be actively enrolled in full-scope Medi-Cal at the time the CGT medication is received
- Have Medi-Cal as their primary health insurance payer
- Receive one of the two CGT medications from a participating manufacturer; and
- Meet all published Medi-Cal policy and all CGT Access Model requirements
Health Plan of San Joaquin/Mountain Valley Health Plan Contacts
Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) is a Medi-Cal Managed Care Plan serving San Joaquin, Stanislaus, El Dorado, and Alpine counties. If you are providing services to a Health Plan member and have any questions or need assistance with prior authorization, please reach out to Health Plan’s contacts for SCD CGT below.
- Primary Point of Contact:
Mike Shook
Director, Care & Utilization Management
HealthplanCGT@hpsj.com
Phone: (209) 800-7232
- Secondary Point of Contact:
NhuAnh Le
Manager, Clinical Pharmacy
HealthplanCGT@hpsj.com
Phone: (209) 309-7578
For additional information and requirements related to the CGT Access Model for Medi-Cal, please visit the following resources:
- DHCS CGT Access Model Webpage: https://www.dhcs.ca.gov/services/ medi-cal-resources/cell-and-gene-therapy-access-model/
- DHCS CGT Provider Manual: https://mcweb.apps.prd.cammis.medi-cal. ca.gov/assets/D1E22E34-A79F-44A5-9F1E-F44904944515/celgenacc.pdf? access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO
- DHCS All Plan Letter (APL) 25-013: https://www.dhcs.ca.gov/wp-content/ uploads/2025/10/APL25-013.pdf
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
