Provider Alert! Prior Authorization Criteria Updates for Yescarta and Tecartus

Date: June 1, 2022

Attention: All Providers

Effective Date: July 1, 2022

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated with 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 (TCHP) would like to inform providers that the Health and Human Services Commission (HHSC) will update prior authorization criteria for Yescarta (Q2041) and Tecartus (Q2053) effective July 1, 2022. The Food and Drug Administration (FDA) approved additional indications for Yescarta and Tecartus. The following are the newly approved indications by the FDA:

• In addition to its current indication, Tecartus is now approved to treat adult clients 18 and older with B-cell Precursor Acute Lymphoblastic Leukemia (ALL).
• In addition to its current indication, Yescarta is now approved to treat adult clients 18 and older who have large B-cell lymphoma that is refractory to first-line chemoimmunotherapy or that relapses within 12 months of first-line chemoimmunotherapy.

How this impacts providers: Prior authorization approval for Tecartus (brexucabtagene autoleucel) treatment in adult clients with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL) will be considered once all the following criteria are met:

• Client is 18 or older
• Client has relapsed or refractory B-cell precursor ALL
• Client has histologically confirmed diagnosis of one of the following:
  • 4  C91.00, C91.01, or C91.02.
• Client does not have primary central nervous system lymphoma/disease
• Client has not received prior CD-19 directed CAR-T therapy
• Client does not have an active infection or inflammatory disorder

Prior authorization approval for Yescarta (axicabtagene ciloleucel) treatment in adults with large B-cell lymphoma that is refractory to first-line chemoimmunotherapy or that relapses within 12 months of first-line chemoimmunotherapy will be considered once all the following criteria are met:

• Client is 18 or older
• Client has large B-cell lymphoma that is refractory to first-line chemoimmunotherapy or that relapses within 12 months of first-line chemoimmunotherapy
• Client has histologically confirmed diagnosis of one of the following:
  • 4  C83.30, C83.31, C83.32, C83.33, C83.34, C83.35, C83.36, C83.37, C83.38, C83.39, C8510, or C8520.
• Client does not have primary central nervous systemlymphoma/disease
• Client has not received prior CD-19 directed CAR-Ttherapy
• Client does not have an active infection or inflammatory disorder

Next steps for providers: Providers should refer to the Outpatient Drug Services Handbook Chapter of the Texas Medicaid Provider Procedure Manual for more details on the clinical policy and prior authorization requirements. Prescribers should also adjust their prescribing patterns accordingly and share this update with their staff.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

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