Patient Access & Insurance Coverage
Coverage and reimbursement for Bristol Myers Squibb CAR T cell therapies may vary based on payer-specific requirements, potential site/setting of care, and patient-specific benefits.
Benefit verification (BV) with a patient’s payer is critical to help identify specific considerations for each appropriate candidate for Bristol Myers Squibb CAR T cell therapies. Our Insurance Coverage Lookup tool can provide information to assist in the BV process, or Cell Therapy 360® can provide BV assistance to verify patient-specific coverage requirements.
Download the CAR T BV checklist for a helpful guide on the type of information that needs to be confirmed during the BV process for CAR T cell therapies.
KEY FACT
Treatment centers should confirm access prior to apheresis scheduling, including BV, prior authorization (PA) approval, and single case agreement (if required).
For questions, please contact your Bristol Myers Squibb Account Representative or call Cell Therapy 360 at 1-888-805-4555.
Bristol Myers Squibb is committed to delivering optimal patient and customer experience with cellular therapies. This information will help appropriate patients get access to our CAR T cell therapies and help treatment centers navigate the reimbursement process.
This information is provided for educational purposes only. Bristol Myers Squibb cannot guarantee insurance coverage or reimbursement. Coverage and reimbursement may vary significantly by payer, plan, patient, and setting of care and is subject to frequent change. It is the sole responsibility of the healthcare provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.
For more information on coverage for CAR T cell therapies, please click each payer type below.
Coverage Policy
CAR T cell therapies are covered by Medicare FFS for FDA-approved use(s) per the National Coverage Determination (NCD), according to which healthcare facilities administering CAR T cell therapy must be certified by the respective manufacturer under the applicable Risk Evaluation and Mitigation Strategy (REMS) program.1
Under the NCD, consistent coverage conditions for CAR T cell therapies apply to all A/B Medicare Administrative Contractor (MAC) jurisdictions.1
Patient Benefits
CAR T cell therapy treatment-related out-of-pocket (OOP) costs for Medicare FFS patients may vary based on:
- Site of care (hospital or clinic) and setting of care (inpatient or outpatient)*
- Secondary or supplemental insurance benefits (eg, employer-sponsored plan, Medigap)
- Inpatient cost-sharing for Medicare FFS patients without secondary or supplemental insurance typically includes an inpatient deductible (up to $1,676 in 2025) and a 20% coinsurance for inpatient physician services2*†
KEY FACT
For Medicare FFS patients without secondary or supplemental insurance, outpatient cost-sharing typically includes a $257 annual deductible (if not yet paid). OOP costs are typically capped per service in the hospital outpatient setting, at the level of the inpatient deductible (up to $1,676 in 2025).2*‡
*Site/setting-of-care decisions are at the sole discretion of the treating physician/institution.
†Under Medicare FFS, an inpatient deductible applies to each inpatient hospital benefit period. After the Part A deductible, there is a $0 copay for inpatient days 1-60.2
‡Full Part B 20% coinsurance applies when outpatient services are provided in an OPPS-exempt hospital or an outpatient clinic/physician office.
Coverage Policy
Although MA plans may issue their own medical policies and PA requirements for FDA-approved CAR T cell therapies, coverage for MA patients must be consistent with the NCD.3,4 Specific PA requirements may vary among MA plans.
Patient Benefits
Patient benefits may vary among MA plans:
- Out-of-network restrictions and referral requirements
- Patient cost-sharing across sites/settings of care*, including:
- Coinsurance
- Copayment
- Annual deductible
- OOP maximum amounts
KEY FACT
For MA patients, OOP costs for Part A and B services are subject to an annual maximum (on average, up to $4,882 for in-network services in 2024).5†
*Site/setting-of-care decisions are at the sole discretion of the treating physician/institution.
†Federal regulations require MA plans to have a limit on annual patient OOP costs for Part A and B services, which are not to exceed $9,350 (in-network) or $14,000 (in-network and out-of-network) in 2025.6
Coverage Policy
CAR T cell therapies are generally covered by commercial plans, typically with detailed PA requirements that are consistent with the FDA-approved labeling.
Specific PA requirements may vary among commercial plans.
Click here for product-specific PA submission tip sheets.
Patient Benefits
Patient benefits may vary among commercial plans:
- Out-of-network restrictions and referral requirements
- Patient cost-sharing across sites/settings of care*, including:
- Coinsurance
- Copayment
- Annual deductible
- OOP maximum amounts
KEY FACT
OOP costs for most commercial patients are subject to an annual maximum (on average, up to $4,409 for in-network services in 2024).7
*Site/setting-of-care decisions are at the sole discretion of the treating physician/institution.
CAR T CELL THERAPY RESOURCES
PRODUCT-SPECIFIC INFORMATION AND CODES
HE-US-2500720 11/25
CAR=chimeric antigen receptor; R/R=relapsed or refractory.
This information is provided for educational purposes only. Bristol Myers Squibb cannot guarantee insurance coverage or reimbursement. Coverage and reimbursement may vary significantly by payer, plan, patient, and setting of care and is subject to frequent change. It is the sole responsibility of the healthcare provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.
References
- Centers for Medicare & Medicaid Services. Decision memo for chimeric antigen receptor (CAR) T-cell therapy for cancers. Accessed April 16, 2025. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=291
- Medicare.gov. Medicare costs. Accessed April 16, 2025. https://www.medicare.gov/basics/costs/medicare-costs
- Centers for Medicare & Medicaid Services Medical Learning Network. Billing instructions for beneficiaries enrolled in Medicare Advantage (MA) plans for services covered by decision memo CAG-00451N. Article Release Date October 24, 2019. Accessed April 16, 2025. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19024.pdf
- Centers for Medicare & Medicaid Services. Medicare managed care manual. Chapter 4 - benefits and beneficiary protections. Revised April 22, 2016. Accessed April 16, 2025. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf
- Freed M, Biniek JF, Damico A, Neuman T. Medicare Advantage in 2024: premiums, out-of-pocket limits, cost sharing, supplemental benefits, prior authorization, and star ratings. KFF. Published August 8, 2024. Accessed April 16, 2025. https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-premiums-out-of-pocket-limits-supplemental-benefits-and-prior-authorization/#
- Centers for Medicare & Medicaid Services. Medicare Drug & Health Plan Contract Administration Group. Published May 6, 2024. Accessed April 16, 2025. https://mabenefitsmailbox.lmi.org/MABenefitsMailbox/ S3Browser/GetFile?path=Final%20CY%202025 %20Standards%20for%20Part%20C%20Benefits.pdf
- 2024 employer health benefits survey. KFF. Published October 9, 2024. Accessed April 16, 2025. https://www.kff.org/health-costs/report/2024-employer-health-benefits-survey/