細胞および遺伝子治療(CGT)アクセスモデル-
Medi-Calメンバーに関するよくある質問(FAQ)
更新日:2025年8月1日
次のFAQは、CGTアクセスモデルに関するMedi-Calメンバー向けの追加のガイダンスと説明を提供します。Department of Health Care Services (DHCS) が追加の質問を受け取り次第、この FAQ は更新されます。CGT Access Modelの一般的な情報については、 一般的なFAQを参照してください。
全般
What might my CGT treatment journey look like under Medi-Cal’s CGT Access Model?
CGT治療を受ける会員の旅には、以下のようなものがあります。
- 血液専門医等への相談
- 身体的ニーズ、行動健康ニーズ、社会的支援ニーズを含む治療センターでの包括的な評価
- 治療プロセスをナビゲートするメンバーと家族のためのケアと支援サービスの調整
- CGTに備えた疾病管理
- 妊孕性保存サービス
- 遺伝子治療の輸液および回復サービス
- 治療後のフォローアップケア
How do I know which CGT SCD medication I will receive through Medi-Cal’s CGT Access Model?
Medi-Cal’s CGT Access Model will cover the two federal Food and Drug Administration (FDA)-approved CGT medications for treatment of sickle cell disease (SCD). This includes, CASGEVY™, which is made by Vertex Pharmaceuticals, Inc., and LYFGENIA™, which is made by bluebird bio, Inc. Your doctor will determine which CGT SCD medication is most appropriate for your individual circumstances and submit the necessary request on your behalf so you can participate in the CGT Access Model and receive the CGT SCD medication.
Can CGT medications for SCD affect my fertility (ability to have children)?
Yes, chemotherapy used in stem cell transplants during CGT treatments may impact your fertility (ability to have children). However, because of this fact, fertility preservation services are covered and available to members under Medi-Cal’s CGT Access Model. You are encouraged to discuss fertility preservation options with your doctor once approved for but before starting CGT treatment. Please see the Covered CGT Access Model Services, Including Fertility Preservation Services section of this FAQ for more information.
合格
Am I eligible to participate in Medi-Cal’s CGT Access Model and receive CGT SCD medications?
Medi-Calメンバーは、次のすべての基準を満たす必要があります。
- -SCDの文書化された医学的診断を持っている。
- CGT薬を受け取った時点で、フルスコープのMedi-Calに積極的に登録している(注:Medi-Calマネージドケアと有料サービス(FFS)メンバーの両方がCGT療法の対象となる場合があります)。
- Medi-Calを主な支払者として持っています。
- 参加プロバイダーから 2 つの CGT 薬のうちの 1 つを受け取ります。そして
- すべてのCGTアクセスモデル要件と、Medi-Calプロバイダーマニュアルおよび該当するAll Plan Letterに概説されている公開されたMedi-Calポリシーを満たします。
CGT アクセス モデル サービスへのアクセス
How do I access CGT SCD medications under Medi-Cal’s GCT Access Model?
If you have Medi-Cal FFS, you should consult with your doctor to determine eligibility and learn more as well as for information on accessing CGT SCD medications. Medi-Cal FFS providers can assist members with accessing one of the two CGT SCD medications.
Medi-Cal managed care members should contact their doctor or Medi-Cal managed care plan (MCP) to determine eligibility and learn more about CGT services. Medi-Cal MCPs are responsible for care coordination and assisting members with accessing one of the two CGT sickle cell disease medications. For more information on Medi-Cal MCP care coordination and other requirements, please review the applicable All Plan Letter on DHCS’ website. Each Medi-Cal MCP includes a point of contact, which can be found in the Medi-Cal Managed Care Health Plan Directory.
If approved for participation in Medi-Cal’s CGT Access Model to receive LYFGENIA, where will that happen?
LYFGENIA treatments are only available and administered at Qualified Treatment Centers (QTCs) centers that have the appropriate experience and training to do so. There are currently eight (8) QTCs that offer LYFGENIA in California, which are bulleted below. You may search for QTCs closest to you on this website: LYFGENIA™ (lovotibeglogene autotemcel) Qualified Treatment Center Locator. Your LYFGENIA patient navigator (available with mybluebirdbio enrollment) may also assist you with identifying a QTC closet to you.
Northern California:
UCSF Benioff Children’s Hospital
Oakland 747 52nd Street, Oakland, CA 94608
510-428-3000
UCSF Benioff Children’s Hospital San Francisco
1975 4th Street, San Francisco, CA 94158
415-476-2188
Lucile Packard Children’s Hospital at Stanford
725 Welch Road, Palo Alto, CA 94304
650-725-3158
南カリフォルニア:
UCLA
757 Westwood Plaza, Los Angeles, CA 90095
310-260-6909
310-825-6708
Children’s Hospital Los Angeles
4650 Sunset Blvd., Los Angeles, CA 90027
323-361-4624
City of Hope National Medical Center
1500 E Duarte Road, Duarte CA, 91010
1-800-826-4673
Loma Linda University Children’s Hospital
11234 Anderson Street, Loma Linda, CA 92354
909-558-4000
Loma Linda University Medical Center
11234 Anderson Street, Loma Linda, CA 92354
909-558-4000
If approved for participation in Medi-Cal’s CGT Access Model to receive CASGEVY, where will that happen?
CASGEVY treatments are only available and administered at Authorized Treatment Centers (ATCs) that have the appropriate experience and training to do so. There are 6 ATCs that offer CASGEVY in California. You may search for ATCs closest to you on this website: Authorized Treatment Center Locator | CASGEVY® (exagamglogene autotemcel).
Northern California:
UCSF Benioff Children’s Hospital San Francisco
1975 4th Street
San Francisco, 94158
Benioff Children’s Hospital Oakland
747 52nd St.
Oakland, 94609
(510) 428-3885 ext. 5183
amy.solari@ucsf.edu
Southern California:
City of Hope National Medical Center
1500 East Duarte Road
Duarte, 91010
(800) 826-4673
genetherapy@coh.org
Children’s Hospital of Orange County
1201 W. La Veta Avenue
Orange, 92868
UCLA Health
757 Westwood Plaza
Los Angeles, 90095
310-260-6909
Children’s Hospital Los Angeles
4650 Sunset Boulevard
Los Angeles, 90027
(323) 361-4624
対象CGTアクセスモデルサービス(妊孕性保存サービスを含む)
What benefits and services can I receive under Medi-Cal’s CGT Access Model?
- CGTアクセスモデルでは、以下の費用が補償されます。
- SCDの2つのCGT薬のうちの1つ
- CASGEVY by Vertex Pharmaceuticals, Inc. – effective October 1, 2025.
- LYFGENIA by bluebird bio, Inc. – effective July 1, 2025.
- SCDの2つのCGT薬のうちの1つ
- 妊孕性保存サービス
- CGT SCD治療薬の償還の一環として、製造業者は以下をカバーします。
- 最大3ラウンドの生殖物質の収集と保存(採卵、精子収集、および/または精巣組織抽出など)。妊孕性保存の正確な技術と種類は、不妊治療専門医とメンバーによって決定され、合意されます。
- 最大15年間のサンプル保管の前払い
- 不妊治療専門医がメンバーが不妊治療サービスに臨床的に適切でないと判断した場合のセカンドオピニオン相談
- 必要に応じて、不妊治療サービスを受けるために、対象となる宿泊費、食事代、および旅費もカバーされる場合があります
- CGT SCD治療薬の償還の一環として、製造業者は以下をカバーします。
モデルに含まれない妊孕性温存サービスにはどのようなものがありますか?
含まれていないサービスの例は次のとおりです。
- 胚(受精卵)作成
- 胚(受精卵)の貯蔵
- 体外受精(プロバイダーの支援を受けて体外で行われます)
リソースに接続するにはどうすればよいですか?
Medi-Cal members who are considering or in the process of receiving bluebird bio’s LYFGENIA gene therapy treatment will receive Patient Navigators through my bluebird support, who can:
- ブルーバードバイオ遺伝子治療の訓練を受けた専門病院である QTCにメンバーをつなぎます。
- 遺伝子治療、不妊治療、鎌状赤血球症、製品固有の情報など、さまざまなトピックに関する教育資料を提供します。
- メンバーが保険の適用範囲と自己負担額を理解し、彼らを財政支援プログラムに結び付けることができるかもしれません。
- 治療の旅を通じてメンバーをサポートし、彼らをリソースにつなげます。
- 旅行や宿泊の支援など、追加の治療関連サポートプログラムの適格性を判断し、調整します
Please note that my bluebird support is available to members at no cost, and there is no obligation to move forward with CGT SCD treatment. To get connected with a Patient Navigator, please complete my bluebird support’s Program Enrollment Form.
Medi-Cal members who are starting treatment with Vertex Pharmaceuticals’ CASGEVY may enroll in Vertex Connects to receive a Case Manager, who can:
- 彼らが有意義なサポートを提供できるように、あなたのことを知るために時間を費やしてください
- 治療プロセスに関する質問に答え、メンバーとその家族が治療の各ステップに備えるのに役立つガイドを共有します
- 治療の旅のロジスティクスをコーディネート
- 旅行や宿泊の支援など、追加の治療関連サポートプログラムの適格性を判断し、調整します
Enrollment in Vertex Connects Patient Support is not required to receive CASGEVY. However, a completed Vertex Connects enrollment form is needed to receive case management services and determine eligibility for certain program offerings. Members will receive a Vertex Connects enrollment form once they are prescribed CASGEVY treatment by their healthcare team.
What expenses are covered for the Medi-Cal member by the CGT therapy manufacturer if travel is necessary to receive fertility preservation services?
CGT therapy manufacturers are responsible for providing reimbursement to eligible members for mileage, tolls, and parking upon presentation of valid receipt, consistent with all applicable manufacturer policy. Manufacturers may also arrange transportation (via air, train, bus, car rental) for the member and caregivers to and from the fertility preservation provider. If an overnight stay is required, CGT therapy manufacturers may provide a modest single hotel room for up to two nights per visit and a reasonable per diem for food expenses for both the member and their parent/caregiver.
For more specific information about eligibility for travel coverage and reimbursement as well as for assistance with travel arrangements, members receiving bluebird bio’s LYFGENIA, should work with their assigned Patient Navigator and utilize my bluebird support. Similarly, members receiving Vertex’s CASGEVY should directly work with their Vertex Connects patient support team.
What benefits and services are NOT part of Medi-Cal’s CGT Access Model and how will I receive them?
Aside from the two CGT medications and, if needed, fertility preservation services, all other medical and non-medical services are not covered under the CGT Access Model and will be provided and covered depending on your Medi-Cal eligibility, as follows:
- Medi-Cal FFSの:
- FFSプロバイダーは、輸送を含む他のすべての医療および非医療CGT関連サービス(上記のように、薬物の費用、妊孕性保存、および適格な宿泊費、食事、および旅費を除く)について、DHCSに直接提供および請求する必要があります。
- Medi-Calマネージドケア:
- メンバーのMedi-Calマネージドケアプランは、交通費を含む他のすべての医療および非医療CGT関連サービスをカバーする必要があります(上記のように、薬の費用、不妊治療の保存、および適格な宿泊費、食事、および旅費を除く)。
フィードバック
Where can I learn more about Medi-Cal’s CGT Access Model and/or provide feedback?
Information about Medi-Cal’s CGT Access Model is available on DHCS’ website, which is available at the following link: Feedback, questions, and comments may also be submitted to DHCS via email at dhcscgt@dhcs.ca.gov.