Prior Authorization Criteria for Tecelra

Date: May 27, 2025

Attention: All Providers

Effective Date: April 1, 2025

Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that Tecelra became a benefit of Medicaid and CHIP. Texas Health and Human services Commission (HHSC) requires prior authorization for Tecelra (procedure code Q2057) for Medicaid and CHIP, effective for dates of service on or after May 1, 2025.

Tecelra (afamitresgene autoleucel) is a melanoma-associated antigen A4 (MAGE-A4)-directed genetically modified autologous T-cell immunotherapy indicated to treat adult patients with unresectable or metastatic synovial sarcoma who have received prior chemotherapy, are HLAA*02:01P, HLA-A*02:02P, HLA-A*02:03P, or HLA-A*02:06P positive, and whose tumor expresses the MAGE-A4 antigen as determined by FDA-approved or cleared companion diagnostic devices.

Prior authorization approval for a one-time Tecelra (afamitresgene autoleucel) Q2057 infusion therapy will be considered when the following criteria are met:

• The patient is 18 years or older.
• The patient has a diagnosis of unresectable or metastatic synovial sarcoma. The patient has one of the following diagnosis codes:

• The tumor is positive for human leukocyte antigen HLA-A*02:01P, HLA-A*02:02P, HLAA*
• 02:03P, and/or HLA-A*02:06P.
• The tumor expresses the MAGE-A4 antigen (as determined by an FDA-approved or cleared companion diagnostic device).
• The patient is not heterozygous or homozygous for HLA-A*02:05P.
• The patient has experienced disease progression following at least one or more prior systemic chemotherapy.
• The patient has not received prior treatment with CAR-T therapy.
• The patient has not had a prior hematopoietic stem cell transplant (HSCT).
• The patient does not have any active or clinically significant infections and/or inflammatory disorders.
• Tecelra (afamitresgene autoleucel), Q2057 is limited to one transfusion treatment per lifetime.

Required Monitoring Parameters

The patient must be monitored for the following parameters for at least seven days following afamitresgene autoleucel (Tecelra) treatment, with continued monitoring for at least four weeks:

• Signs and symptoms of cytokine release syndrome (CRS)
• Signs and symptoms of immune effector cell-associated neurotoxicity syndrome (ICANS)

Refer to the Outpatient Drug Services Handbook Chapter of the Texas Medicaid Provider

Procedure Manual (TMPPM) for more details on the clinical policy and prior authorization requirements.

Next step for providers: Providers are encouraged to share this communication with staff.

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

For access to all provider alerts,log into: 
https://www.texaschildrenshealthplan.org/provideralerts.