OH Epic Formulary, available via Beacon Treatment Plan, restricted to: 

• Service Line: Oncology/Hematology 
• Formulary Location: Inpatient, outpatient infusion 
• Service location: Inpatient, outpatient infusion center, home infusion 
• Patient Population: Adult patients 
• Prior Authorization Required: Yes (outpatient) 
• Restriction/Criteria of Use (all will apply unless specified):
  • Large B-cell lymphoma, relapsed/refractory < 12 months of first line therapy 
  • Radiographically documented disease 
  • No central nervous system lymphoma involvement 
  • >2 weeks since prior systemic cancer therapy 
  • Adequate bone marrow, renal, hepatic, and pulmonary, and cardiac function (consistent with ZUMA-7 or ZUMA 5 requirements) 
  • Eastern Cooperative Oncology Group performance status (ECOG-PS) of 0 or 1 
  • Negative pregnancy test 
  • Healthcare facilities that dispense and administer Yescarta must be enrolled and comply with the YESCARTA and TECARTUS REMS requirements

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