Health Net
Tecartus (brexucabtagene autoleucel)
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: Acute Lymphoblastic Leukemia:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 3 Month(s)

  • Acute Lymphoblastic Leukemia:
    Age Requirement: >= 18
    Duration: 3 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): 1 of Hematologist;Oncologist
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: FDA Approved Indications
    Diagnosis Types: 2 of First relapse following a remission lasting less than 12 months;Primary refractory disease;Relapsed or refractory B-cell ALL;Relapsed or refractory disease after 2 or more lines of systemic therapy;Relapsed or refractory disease at least 100 days after allogenic stem cell transplantation (HSCT);Relapsed/refractory Ph+ B-cell ALL that is refractory to 2 TKIs
    ECOG Score Requirement Included in Policy: N/A
    Contraindications: CNS disorders
    Specialty Pharmacy is Required: Not Defined