Prior Authorization Criteria for Tecartus Updated January 1, 2021

Date: January 26, 2021 Attention: Oncologists Effective Date: January 1, 2021Providers 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 (TCHP) follows the clinical prior authorization criteria for Tecartus (Procedure Code C9073), presented by the Health and Human Services Commission (HHSC). Tecartus (C9073) is a benefit for individuals with the diagnosis of relapsed or refractory mantel cell lymphoma (MCL). Procedure code C9073 is limited to once per lifetime administration. The drug must be prescribed by or in consultation with an oncologist and treatments must take place in a certified healthcare facility. Certified healthcare facilities must enroll and comply with the Risk Evaluation and Mitigation Strategies requirements for each drug administered under this policy. How this impacts providers: Medicaid approves prior authorization requests for brexucabtagene autoleucel (Tecartus) infusion when the following criteria are met:

A histologically confirmed diagnosis of relapse or refractory MCL (diagnosis codes C8310, C8311, C8312, C8313, C8314, C8315, C8316, C8317, C8318 and C8319)
18 years of age or older

- Patient has received adequate therapy and has had at least one of the following systemic treatments for MCL prior to brexucabtagene autoleucel therapy:

Anthracycline or bendamustine-containing chemotherapy
Anti-CD 20 monoclonal antibody therapy
Bruton Tyrosine Kinase inhibitors (e.g. ibrutinib or acalabrutinib)

- The person:

does not have primary central nervous system lymphoma/disease
does not have an active infection or inflammatory disorder
has not received prior CD-19 directed CAR-T therapy

Brexucabtagene autoleucel (Tecartus) is not a benefit for clients who have the following:

An active infection or inflammatory disorder
Primary central nervous system lymphoma

Next steps for providers: Providers should share this communication 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.