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Prior Authorization Criteria for Obecabtagene Autoleucel (Aucatzyl) Effective August 1, 2025

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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 August 1, 2025, providers must obtain prior authorization for obecabtagene autoleucel (Aucatzyl), procedure code Q2058. Obecabtagene autoleucel (Aucatzyl) may be approved for a duration of 12 months.

Prior Authorization Requirements for Obecabtagene Autoleucel (Aucatzyl)

Obecabtagene autoleucel (Aucatzyl) is a CD19-directed genetically modified autologous T-cell immunotherapy that is indicated for clients who are 18 years of age or older.

Providers must submit a Special Medical Prior Authorization (SMPA) Request Form with their prior authorization requests for obecabtagene autoleucel (Aucatzyl) and documentation that verifies all the following:

  • The client is 18 years of age and older.
  • The client has a confirmed diagnosis of relapsed or refractory B-cell precursor ALL (diagnosis code C9100 or C9102).
  • The client has adequate cardiac, hepatic, pulmonary, and renal function.
  • A bone marrow blast assessment was conducted, and results from the sample were obtained in order to start lymphodepleting chemotherapy.
  • The client does not have a clinically significant active infection or inflammatory disorder.
  • The client has been screened and does not have active/latent Hepatitis B virus, active Hepatitis C virus, or human immunodeficiency virus (HIV).
  • The client has not previously received chimeric antigen receptor (CAR)-T therapy.

Obecabtagene autoleucel (Aucatzyl) (procedure code 1-Q2058) is limited to a one-time cell suspension therapy with split dose infusion treatment.

Required Monitoring Parameters

The client must be monitored daily for signs and symptoms of cytokine release syndrome (CRS), neurologic toxicities/immune effector cell-associated neurotoxicity syndrome (ICANS), and other acute toxicities for at least 14 days at the health care facility following obecabtagene autoleucel (Aucatzyl) infusion.

Blood counts must be monitored for cytopenia (e.g., anemia, neutropenia, or thrombocytopenia) and secondary malignancies.

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