Provider Alert! Abecma available on Medicaid formulary with prior authorization requirements

Date: October 26, 2021

Attention: Oncologists

Effective Date: October 1, 2021

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Prescribers should be aware that Abecma (procedure code C9081) will be available to members through Texas Medicaid pharmacy benefit effective October 1, 2021. Access will require meeting clinical prior authorization criteria for Abecma (Idecabtagene vicleucel).  Abecma is indicated for treatment of adults (> 18 years of age) with relapsed or refractory multiple myeloma.

Idecabtagene vicleucel (Abecma) is limited to once per lifetime.

How this impacts providers: A prior authorization of therapy will be approved for members who meet the following criteria:

• Client is 18 years of age or older
• Client has histologically confirmed diagnosis of relapse or refractory multiple myeloma (diagnosis code: C9000 and C9002)
• Client must have received four or more prior lines of the following therapies before treatment with idecabtagene vicleucel:
• An immunomodulatory agent
• A proteasome inhibitor
• An anti-CD38 monoclonal antibody
• Client does not have primary central nervous system lymphoma/disease
• Client does not have an active infection or inflammatory disorder
• Client has not received prior CAR-T therapy

Next steps for providers: Prescribers should adjust their prescribing patterns accordingly and communicate these changes to their staff.

If you have any questions, please email the TCHP Pharmacy team at: TCHPPharmacy@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.