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

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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.

This is an update to the article titled “Prior Authorization Criteria for CAR T-Cell Therapy to Change Effective August 1, 2024,” which was published on the Texas Medicaid & Healthcare Partnership (TMHP) website on July 12, 2024.

Lisocabtagene Maraleucel (Breyanzi)

Prior authorization approval for lisocabtagene maraleucel (Breyanzi) (procedure code Q2054) infusion therapy will be considered when the client meets the following criteria:

  • The client has histologically confirmed diagnosis of large B-cell lymphoma including diffuse large B-cell lymphoma (DLBCL) not otherwise specified (including DLBCL arising from indolent lymphoma), high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, and follicular lymphoma grade 3B with one of the following:
    • Refractory disease to first-line chemoimmunotherapy or relapse within 12 months of first-line chemoimmunotherapy
    • Refractory disease to first-line chemoimmunotherapy or relapse after first-line chemoimmunotherapy and is not eligible for hematopoietic stem cell transplant (HSCT) due to comorbidities or age
    • Relapsed or refractory disease after two or more lines of systemic therapy.
  • The client has confirmed diagnosis of 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 confirmed diagnosis of elapse or refractory follicular lymphoma and has received two or more lines of systemic therapy.
  • The client has confirmed diagnosis of relapse or refractory mantle cell lymphoma (MCL) and has received at least two prior lines of systemic therapy.
  • The client has one of the following lymphoma diagnosis codes:
Diagnosis Codes for Lisocabtagene Maraleucel (Breyanzi)
C8200C8201C8202C8203C8204C8205C8206
C8207C8208C8209C8210C8211C8212C8213
C8214C8215C8216C8217C8218C8219C8220
C8221C8222C8223C8224C8225C8226C8227
C8228C8229C8230C8231C8232C8233C8234
C8235C8236C8237C8238C8239C8240C8241
C8242C8243C8244C8245C8246C8247C8248
C8249C8250C8280C8281C8282C8283C8284
C8285C8286C8287C8288C8289C8290C8291
C8292C8293C8294C8295C8296C8297C8298
C8299C8300C8301C8302C8303C8304C8305
C8306C8307C8308C8309C8310C8311C8312
C8313C8314C8315C8316C8317C8318C8319
C8330C8331C8332C8333C8334C8335C8336
C8337C8338C8339C8390C8391C8392C8393
C8394C8395C8396C8397C8398C8399C8510
C8511C8512C8513C8514C8515C8516C8517
C8518C8519C8520C8521C8522C8523C8524
C8525C8526C8527C8528C8529C8580C8581
C8582C8583C8584C8585C8586C8587C8588
C8589C9110C9112    

Ciltacabtagene Autoleucel (Carvykti)

The Food and Drug Administration (FDA) has updated the criteria for clients who have relapsed or refractory disease and have received at least one line of systemic therapies before treatment with ciltacabtagene autoleucel (Carvykti).

The lines of systemic therapies have decreased from four or more to at least one in the following criterion:

  • Clients have relapsed or refractory disease, are refractory to lenalidomide, and have received at least one line of the following systemic therapies before treatment with ciltacabtagene autoleucel (Carvykti):
    • A proteasome inhibitor
    • An immunomodulatory agent

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