Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsFlorida AHCA ABECMA Coverage Policy | OpenPayer
    Ask Trek AI about this page
    CurrentAgency for Health Care AdministrationPolicy N/A

    ABECMA (idecabtagene vicleucel) Coverage and Prior Authorization

    Customize your policy alerts

    Sign up for all Agency for Health Care Administration policy alerts

    Know when Agency for Health Care Administration releases new policies or updates existing guidance.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs prior authorization and administration of ABECMA (idecabtagene vicleucel) for adults with relapsed or refractory multiple myeloma in hospital inpatient or outpatient settings.

    Policy Summary
    PayerAgency for Health Care Administration
    PolicyABECMA (idecabtagene vicleucel) Coverage and Prior Authorization
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMay 7, 2021
    Next Review DateN/A
    Key ActionSubmit documentation confirming the patient is at least 18 years old, has relapsed or refractory multiple myeloma, and has failed at least four prior therapy lines.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ≥18 yearsMinimum patient age
    4+ linesMinimum prior therapy lines
    300–460 × 10^6Recommended CAR-positive T-cell dose
    Inpatient/outpatientAdministration settings
    ABECMA REMSSafety program

    Coverage Criteria

    Initial ABECMA Therapy

    Coverage is provided when ALL of the following criteria are met:

    ALL of the following

    • The patient is 18 years of age or older.
    • The patient has a diagnosis of relapsed or refractory multiple myeloma.
    • The patient has tried and failed at least 4 lines of prior therapy, including an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 monoclonal antibody.

    Initial Therapy Eligibility

    Initial Therapy Eligibility

    Initial therapy is covered when all of the following are met:

    ABECMA initial therapy eligibility

    • Age: The patient is at least 18 years of age.≥18 years
    • Diagnosis: The patient has relapsed or refractory multiple myeloma.
    • Prior therapy: The patient has tried and failed at least four lines of prior therapy, including an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 monoclonal antibody.At least 4 prior lines

    Authorization and Safety Requirements

    Documentation Required

    Clinical Eligibility Documentation

    Document that the patient meets all clinical eligibility requirements for ABECMA prior authorization.

    • Patient is ≥ 18 years of age.
    • Patient has a diagnosis of relapsed or refractory multiple myeloma.
    • Patient has tried and failed at least 4 lines of prior therapy, including an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 monoclonal antibody.
    Prior Authorization

    ABECMA REMS Enrollment Required

    ABECMA must be provided only through the restricted ABECMA Risk Evaluation and Mitigation Strategy (REMS) program because of the risks of cytokine release syndrome, neurological toxicities, hemophagocytic lymphohistiocytosis/macrophage activation syndrome, and prolonged cytopenia.

    • Enroll and comply with the ABECMA REMS before providing treatment.
    • Additional information is available at www.AbecmaREMS.com or 1-888-423-5436.
    Denial Risk

    Failure to Meet Clinical Eligibility Criteria

    Authorization may be denied when the patient does not meet the required clinical eligibility criteria for ABECMA.

    • Patient is younger than 18 years of age.
    • Patient does not have relapsed or refractory multiple myeloma.
    • Patient has not tried and failed at least 4 lines of prior therapy, including an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 monoclonal antibody.

    Permitted Administration Settings

    Note

    Hospital outpatient administration permitted

    ABECMA administration is permitted in a hospital outpatient setting.

    Note

    Hospital inpatient administration permitted

    ABECMA administration is permitted in a hospital inpatient setting.

    Key Definitions

    ABECMA REMS
    ProgramABECMA Risk Evaluation and Mitigation Strategy (REMS)
    PurposeA restricted safety program for ABECMA because of the risks of cytokine release syndrome, neurological toxicities, hemophagocytic lymphohistiocytosis/macrophage activation syndrome, and prolonged cytopenia.
    Access requirementABECMA is available only through the restricted ABECMA REMS program.
    CAR-positive T cells
    DefinitionT cells modified to express a chimeric antigen receptor (CAR).
    Dosing basisABECMA dosing is based on the number of CAR-positive T cells.
    Recommended dose range300 to 460 × 10^6 CAR-positive T cells.

    Therapy Background

    ABECMA (idecabtagene vicleucel) is a CAR-positive T-cell therapy used for adults with relapsed or refractory multiple myeloma after extensive prior treatment. Coverage requires that the patient be at least 18 years of age and have tried and failed at least four prior lines of therapy, including an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 monoclonal antibody.

    Treatment with ABECMA carries risks of cytokine release syndrome, neurological toxicities, hemophagocytic lymphohistiocytosis/macrophage activation syndrome, and prolonged cytopenia. Because of these serious risks, ABECMA is available only through the restricted ABECMA REMS program.

    Policy Summary
    PayerAgency for Health Care Administration
    PolicyABECMA (idecabtagene vicleucel) Coverage and Prior Authorization
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateMay 7, 2021
    Next Review DateN/A
    Key ActionSubmit documentation confirming the patient is at least 18 years old, has relapsed or refractory multiple myeloma, and has failed at least four prior therapy lines.
    SourceLink
    On This Page
    Coverage CriteriaInitial Therapy EligibilityAuthorization and Safety RequirementsPermitted Administration SettingsKey DefinitionsTherapy Background

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.