Payment: Claims for Q2042 must be manually adjudicated
Pay quarter: N/A
Dosage and Frequency
• 0.2 to 5.0 x 10^6 CAR-positive viable T cells per kg IV if patient weighs 50kg or below
• 0.1 to 2.5 x 10^8 CAR-positive viable T cells IV if patient weighs above 50kg
Calculate drug reimbursement
(ASP: N/A, Margin: N/A)
# Units to bill:N/A
Prior auth criteria for Kymriah may include but is not limited to:
1. The patient must have a confirmed diagnosis of either B-cell precursor acute lymphoblastic leukemia (ALL) or diffuse large B-cell lymphoma (DLBCL).
2. The patient must have disease that is refractory or relapsed after at least one prior systemic therapy.
3. The patient must be at least 25 or younger at the time of diagnosis with ALL or 18 or younger at the time of diagnosis with DLBCL.
4. The patient must have a Karnofsky performance score of at least 50.
5. The patient must have adequate organ function as assessed by laboratory tests.
6. The patient must have a hematopoietic stem cell donor available or have had successful mobilization.
7. The patient must have no active or uncontrolled infections.
8. The patient must have no active central nervous system involvement.
9. The patient must have no contraindications to lentiviral vector-based therapy.
10. The patient must not have had prior allogeneic stem cell transplant.
Insurance prior auth guidelines: