Provider Alert! Prior Authorization Criteria to Change for Some CAR T-Cell Infusion Therapies 

Date: September 13, 2022

Attention: All Providers

Effective Date: September 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 the prior authorization criteria for Yescarta (Q2041), Breyanzi (Q2054) and Kymriah (Q2042) effective September 1, 2022.

How this impacts providers: Prior authorization approval for Yescarta treatment in adult clients with large B-cell lymphoma will be considered once all the following criteria are met:

• Client is 18 years of age or older.
• Client has relapsed or refractory disease defined as progression after two or more lines of systemic therapy (which may or may not include therapy supported by autologous stem cell transplant).
• Client does not have primary central nervous system lymphoma/disease.
• Client has not received prior CD-19 directed CAR-T therapy.
• One of the following diagnosis codes C8200 C8201 C8202 C8203 C8204 C8205 C8206 C8207 C8208 C8209 C8210 C8211 C8212 C8213 C8214 C8215 C8216 C8217 C8218 C8219 C8220 C8221 C8222 C8223 C8224 C8225 C8226 C8227 C8228 C8229 C8230 C8231 C8232 C8233 C8234 C8235 C8236 C8237 C8238 C8239 C8240 C8241 C8242 C8243 C8244 C8245 C8246 C8247 C8248 C8249 C8250 C8251 C8252 C8253 C8254 C8255 C8256 C8257 C8258 C8259 C8260 C8261 C8262 C8263 C8264 C8265 C8266 C8267 C8268 C8269 C8280 C8281 C8282 C8283 C8284 C8285 C8286 C8287 C8288 C8289 C8290 C8291 C8292 C8293 C8294 C8295 C8296 C8297 C8298 C8299.

Prior authorization approval for Breyanzi treatment in adult clients with large B-cell lymphoma will be considered once all the following criteria are met:

• Client is 18 years of age or older.
• Client has a histologically confirmed diagnosis of large B-cell lymphoma, including diffuse large B-cell lymphoma not otherwise specified (including DLBCL arising from indolent lymphoma), high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, or follicular lymphoma grade 3B with one of the following:
  • Refractory disease to first-line chemoimmunotherapy or relapse within 12 months of first line chemoimmunotherapy; or
  • Refractory disease to first-line chemoimmunotherapy or relapse after first line chemoimmunotherapy, and are not eligible for hematopoietic stem cell transplant (HSCT) due to comorbidities or age; or
  • Relapsed or refractory disease after two or more lines of systemic therapy.
• Client has histologically confirmed diagnosis of one of the following:

C8240 C8241 C8242 C8243 C8244 C8245 C8246 C8247 C8248 C8249 C8250 C8330 C8331 C8332 C8333 C8334 C8335 C8336 C8337 C8338 C8339 C8390 C8391 C8392 C8393 C8394 C8395 C8396 C8397 C8398 C8399 C8510 C8511 C8512 C8513 C8514 C8515 C8516 C8517 C8518 C8519 C8520 C8521 C8522 C8523 C8524 C8525 C8526 C8527 C8528 C8529 C8580 C8581 C8582 C8583 C8584 C8585 C8586 C8587 C8588 C8589

• Client does not have primary central nervous systemlymphoma/disease.
• Client has not received prior CD-19 directed CAR-T
• Client does not have an active infection or inflammatory disorder.

Prior authorization approval for Kymriah treatment in adult clients with relapsed or refractory follicular lymphoma (FL) will be considered once all the following criteria are met:

• Client is 18 years of age or older.
• Client has relapsed or refractory disease, defined as progression after two or more lines of systemic therapy.
• 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.
• Client has a histologically confirmed diagnosis of one of the following types of follicular lymphoma:

C8200 C8201 C8202 C8203 C8204 C8205 C8206 C8207 C8208 C8209 C8210 C8211 C8212 C8213 C8214 C8215 C8216 C8217 C8218 C8219 C8220 C8221 C8222 C8223 C8224 C8225 C8226 C8227 C8228 C8229 C8230 C8231 C8232 C8233 C8234 C8235 C8236 C8237 C8238 C8239 C8240 C8241 C8242 C8243 C8244 C8245 C8246 C8247 C8248 C8249 C8250 C8251 C8252 C8253 C8254 C8255 C8256 C8257 C8258 C8259 C8260 C8261 C8262 C8263 C8264 C8265 C8266 C8267 C8268 C8269 C8280 C8281 C8282 C8283 C8284 C8285 C8286 C8287 C8288 C8289 C8290 C8291 C8292 C8293 C8294 C8295 C8296 C8297 C8298 C8299

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.

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

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