Pharmacy Prior Authorization Criteria

Yescarta (axicabtagene ciloleucel) - PA, NF

Indications for Prior Authorization

Yescarta (axicabtagene ciloleucel)

• For diagnosis of Large B-cell Lymphoma
  Indicated for the treatment of (1) adult patients with large B-cell lymphoma that is refractory to first-line chemoimmunotherapy or that relapses within 12 months of first-line chemoimmunotherapy, or (2) adult patients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy, including diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma, high grade B-cell lymphoma, and DLBCL arising from follicular lymphoma.

• For diagnosis of Follicular Lymphoma
  Indicated for the treatment of adult patients with relapsed or refractory follicular lymphoma (FL) after two or more lines of systemic therapy. This indication is approved under accelerated approval based on response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trial(s).

Criteria

Yescarta

Prior Authorization, Non Formulary

Length of Approval: 1 Time Authorization in Lifetime
For diagnosis of Large B-cell Lymphoma

• One of the following:
• Submission of medical records (e.g., chart notes) confirming both of the following:
• Diagnosis of large B-cell lymphoma
AND
• Disease is one of the following:
• Refractory to first line chemoimmunotherapy
• Relapsed within 12 months of first line chemoimmunotherapy
OR
• Submission of medical records (e.g., chart notes) confirming all of the following:
• Diagnosis of one of the following:
• Diffuse large B-cell lymphoma not otherwise specified (DLBCL-NOS)
• Primary mediastinal large B-cell lymphoma
• High grade B-cell lymphoma
• DLBCL arising from follicular lymphoma
AND
• Disease is one of the following:
• Relapsed
• Refractory
AND
• Patient has received two or more prior lines of systemic therapy for large B-cell lymphoma (e.g., chemotherapy)
AND
• Provider attests to both of the following:
• Patient does not have signs or symptoms of clinically significant active infection
AND
• Patient does not have an active inflammatory disorder (e.g., uncontrolled rheumatoid arthritis, uncontrolled ulcerative colitis)
AND
• Provider attests that patient has never received Yescarta treatment in their lifetime
AND
• Prescribed by or in consultation with an oncologist with expertise in CAR T-cell therapy at an authorized treatment center for Yescarta with shared-decision-making regarding treatment risks

Yescarta

Prior Authorization, Non Formulary

Length of Approval: 1 Time Authorization in Lifetime
For diagnosis of Follicular Lymphoma

• Submission of medical records (e.g., chart notes) confirming all of the following:
• Diagnosis of follicular lymphoma (FL)
AND
• Disease is one of the following:
• Relapsed
• Refractory
AND
• Patient has received two or more prior lines of systemic therapy for FL (e.g., chemotherapy)
AND
• Provider attests to both of the following:
• Patient does not have signs or symptoms of clinically significant active infection
AND
• Patient does not have an active inflammatory disorder (e.g., uncontrolled rheumatoid arthritis, uncontrolled ulcerative colitis)
AND
• Provider attests that patient has never received Yescarta treatment in their lifetime
AND
• Prescribed by or in consultation with an oncologist with expertise in CAR T-cell therapy at an authorized treatment center for Yescarta with shared-decision-making regarding treatment risks

P & T Revisions

2026-04-20

References

1. Yescarta Prescribing Information. Kite Pharma, Inc.Santa Monica, CA. February 2026.

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Revision History

• 2026-04-20: New Program.

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