Formulary restrictions:

• Service Line: Hematology/Oncology
• Formulary Location: Inpatient and Outpatient infusion
• Service location: Inpatient, Outpatient infusion
• Patient Population: Adults
• Prior Authorization Required: Yes for outpatient infusion, single case agreement will be needed based on payor
• Criteria of Use (all will apply unless specified):
• Mantle-cell lymphoma, relapsed or refractory with receipt of previous BTK inhibitor therapy OR B-cell precursor acute lymphoblastic leukemia, relapsed or refractory with morphological disease in the bone marrow (>5% blasts)
• No CNS lymphoma or leukemia involvement
• Eastern Cooperative Oncology Group performance status (ECOG-PS) of 0 or 1
• Negative pregnancy test
• Healthcare facilities that dispense and administer TECARTUS must be enrolled and comply with the YESCARTA and TECARTUS REMS requirements

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