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Prior Authorization Criteria for Brexucabtagene Autoleucel (Tecartus) Effective January 1, 2021

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after January 1, 2021, prior authorization is required for brexucabtagene autoleucel (Tecartus) (procedure code C9073) for Texas Medicaid.

Brexucabtagene autoleucel (Tecartus) is indicated to treat adult clients with relapsed or refractory mantel cell lymphoma (MCL). Procedure code C9073 is limited to once per lifetime.

Prior authorization approval of brexucabtagene autoleucel (Tecartus) (procedure code C9073) infusion therapy will be considered when all of the following criteria are met:

  • The client must have a histologically confirmed diagnosis of relapse or refractory MCL (diagnosis codes C8310, C8311, C8312, C8313, C8314, C8315, C8316, C8317, C8318 and C8319).
  • The client is 18 years of age or older.
  • The client has received adequate therapy and has had at least one of the following systemic treatments for MCL prior to brexucabtagene autoleucel therapy:
    • Anthracycline or bendamustine-containing chemotherapy
    • Anti-CD 20 monoclonal antibody therapy
    • Bruton Tyrosine Kinase inhibitors (e.g., ibrutinib or acalabrutinib)
  • The client does not have primary central nervous system lymphoma/disease.
  • The client does not have an active infection or inflammatory disorder.
  • The client has not received prior CD-19 directed CAR-T therapy.

Note: Prior authorization criteria for axicabtagene ciloleucel (Yescarta) and tisagenlecleucel (Kymriah) also includes the client not having received prior CD-19 directed CAR-T therapy.

Brexucabtagene autoleucel (Tecartus) is not a benefit for clients who have the following:

  • An active infection or inflammatory disorder
  • Primary central nervous system lymphoma

For more information, call the TMHP Contact Center at 800-925-9126.