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Prior Authorization Criteria for CAR T-Cell Therapy to Change Effective August 1, 2024

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This article has been updated. To view the updated information, see Update to “Prior Authorization Criteria for CAR T-Cell Therapy to Change Effective August 1, 2024”.

 

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 August 1, 2024, prior authorization criteria for Texas Medicaid will change for the following chimeric antigen receptor (CAR) t-cell therapies.

Lisocabtagene Maraleucel (Breyanzi)

The following prior authorization criteria for lisocabtagene maraleucel (Breyanzi) procedure code Q2054 will be added:

  • The client has relapsed or refractory chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) and has received at least two prior lines of therapy, including a Bruton tyrosine kinase (BTK) inhibitor and a B-cell lymphoma 2 (BCL-2) inhibitor.
  • The client has relapsed or refractory follicular lymphoma after receiving two or more lines of systemic therapy.
  • The client has relapsed or refractory mantle cell lymphoma (MCL) after receiving at least two prior lines of systemic therapy.

The following lisocabtagene maraleucel (Breyanzi) diagnosis codes will be added:

Diagnosis Codes
C8200C8201C8202C8203C8204C8205C8206
C8207C8208C8209C8210C8211C8212C8213
C8214C8215C8216C8217C8218C8219C8220
C8221C8222C8223C8224C8225C8226C8227
C8228C8229C8230C8231C8232C8233C8234
C8235C8236C8237C8238C8239C8280C8281
C8282C8283C8284C8285C8286C8287C8288
C8289C8290C8291C8292C8293C8294C8295
C8296C8297C8298C8299C8300C8301C8302
C8303C8304C8305C8306C8307C8308C8309
C8310C8311C8312C8313C8314C8315C8316
C8317C8318C8319C9110C9112  

Ciltacabtagene Autoleucel (Carvykti)

The number of systemic therapies has changed from four or more lines to one or more lines in the following criterion:

  • Clients have relapsed or refractory disease and have received one or more lines of the following systemic therapies before treatment with ciltacabtagene autoleucel (Carvykti) which must include:
    • A proteasome inhibitor
    • An immunomodulatory agent
    • An anti-CD38 monoclonal antibody

Idecabtagene Vicleucel (Abecma)

The number of systemic therapies has changed from four or more lines to two or more lines in the following criterion:

  • The client must have received two or more lines of the following therapies before treatment with idecabtagene vicleucel (Abecma):
    • An immunomodulatory agent
    • A proteasome inhibitor
    • An anti-CD-38 monoclonal antibody

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