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Some Criteria to Change for Axicabtagene Ciloleucel (Yescarta) Effective November 1, 2023

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after November 1, 2023, Texas Medicaid will update the prior authorization criteria for axicabtagene ciloleucel (Yescarta).

Criteria for Clients with Large B-Cell Lymphoma

Current prior authorization criteria will be updated to clarify the indications for axicabtagene ciloleucel (Yescarta). Prior authorization approval will be considered for the treatment of either of the following conditions:

  • Relapsed or refractory disease, defined as progression after two or more lines of systemic therapy (which may or may not include therapy supported by autologous stem cell transplant)
  • Large B-cell lymphoma that is refractory to first-line chemoimmunotherapy or that relapses within 12 months of first-line chemoimmunotherapy

Current prior authorization criteria also include the following requirements:

  • The client does not have primary central nervous system lymphoma or disease.
  • The client does not have an active infection or inflammatory disorder.
  • The client has not received prior CD-19–directed chimeric antigen receptor (CAR) T-cell therapy.

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.24.1, “Prior Authorization Criteria for Axicabtagene Ciloleucel (Yescarta),” for additional prior authorization requirements for clients with large B-cell lymphoma.

Criteria for Clients with Follicular Lymphoma

Current prior authorization criteria include the following requirement:

  • The client does not have an active infection or inflammatory disorder.

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.24.1, “Prior Authorization Criteria for Axicabtagene Ciloleucel (Yescarta),” for additional prior authorization requirements for clients with follicular lymphoma.

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