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

Provider Alert!

Provider Alert! Breyanzi 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 Breyanzi (procedure code Q2054) will be available to members through Texas Medicaid pharmacy benefit effective October 1, 2021. Access will require meeting clinical prior authorization criteria for Breyanzi (Lisocabtagene Maraleucel).  Breyanzi is indicated for treatment of adults (> 18 years of age) with relapsed or refractory large B-cell lymphoma.

Lisocabtagene Maraleucel (Breyanzi) is limited to once per lifetime.

How this impacts providers: A manual 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 diffuse large B-cell lymphoma including diffuse large B-cell lymphoma not otherwise specified (including diffuse large B-cell lymphoma arising from indolent lymphoma), high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, and follicular lymphoma grade 3B.
  • Client has relapsed or refractory disease after receiving at least two lines of systemic therapy.
  • Client has a type of lymphoma specified by one of the diagnosis codes in the attached document
  • 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 CD-19 directed 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:

For access to all provider alerts, log into: or

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