Provider Alert! Yescarta Prior Authorization Criteria Update

Date: December 7, 2021

Attention: Oncologists

Effective Date: November 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: Texas Children’s Health Plan updated the clinical prior authorization criteria for Yescarta (procedure code Q2041) to align with the recent FDA indication expansion and guidance from the Texas Health and Human Services (HHSC).

Effective November 1, 2021, adult patients 18 years of age and older with relapsed or refractory follicular lymphoma (FL) after two or more lines of systemic therapy, are eligible to receive Yescarta.

How this impacts providers: Prior authorization approval for Yescarta treatment in adult clients with relapsed or refractory follicular lymphoma (FL) after two or more lines of systemic therapy will be considered once all the following criteria are met:

• Client is 18 years of age or older
• Client must have relapsed or refractory disease as progression after two or more lines of systemic therapy (which may or may not include therapy supported by autologous stem cell transplant)
• Client has a histologically confirmed diagnosis of one of the following types of follicular lymphoma: 4 C8200, C8201, C8202, C8203, C8204, C8205, C8206, C8207, C8208, C8209.
• Client does not have primary central nervous system lymphoma/disease
• 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 TCHP Pharmacy Department at: TCHPPharmacy@texaschildrens.org.

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