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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsBaylor Scott & White Abecma Coverage | OpenPayer
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    CurrentBaylor Scott & White Health PlanPolicy 290

    Idecabtagene vicleucel (Abecma) Coverage

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    This policy governs prior authorization and medical-necessity review for idecabtagene vicleucel (Abecma), a BCMA-directed CAR-T therapy. It applies across lines of business unless the applicable benefit plan, federal rule, or state rule provides otherwise.

    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyIdecabtagene vicleucel (Abecma) Coverage
    Policy CodePolicy 290
    Change TypeRevised
    Effective DateAug 1, 2026
    Last ReviewJun 25, 2026
    Next Review DateJun 25, 2027
    Key ActionSubmit prior authorization documentation showing that all medical-necessity criteria are met.
    SourceLink
    POLICY UPDATE CHANGES

    Eligibility criteria were updated to require monotherapy and add examples of BCMA-targeted therapy, allogeneic and autologous stem-cell-transplant exclusions, and central-nervous-system exclusion criteria.

    Criterion 10 was updated to specify examples of immunomodulatory agents, proteasome inhibitors, and anti-CD38 monoclonal antibodies among prior therapies.

    REMS criteria for idecabtagene vicleucel were removed.

    The CPT and HCPCS coding sections were updated.

    ≥18Minimum member age

    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.

    2+ lines
    Prior systemic therapy
    3 classesRequired therapy classes
    1 treatmentLifetime treatment limit
    ECOG 0–1Performance status
    PA requiredUtilization management

    Coverage Criteria and Exclusions

    Initial therapy

    BSWHP may consider idecabtagene vicleucel medically necessary when documentation is submitted showing ALL of the following criteria are met.

    Initial medical-necessity criteria

    • Required prior therapy classes: The member has received two or more prior lines of systemic therapy, including an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 monoclonal antibody.At least 2 prior systemic therapy lines; all 3 therapy classes required

      Examples include lenalidomide, pomalidomide, or thalidomide; bortezomib, carfilzomib, or ixazomib; and daratumumab, elotuzumab, or isatuximab.

    Lifetime treatment limit

    Only one treatment per lifetime is medically necessary.

    Lifetime treatment limitation: Idecabtagene vicleucel may be covered for no more than one treatment per lifetime. Repeat administration is experimental and investigational because the effectiveness of this strategy has not been established.1 treatment per lifetime

    This is a coverage limitation rather than a continuation-therapy pathway.

    Coverage requires documentation that the member has no active infection, including hepatitis B, hepatitis C, or HIV infection; inflammatory disorder; history of allogeneic stem-cell transplant; or autologous stem-cell transplant performed 12 weeks or less before apheresis. The member must also have no known active or prior central nervous system involvement, or clinical signs of meningeal involvement, of multiple myeloma.

    The member must not have received prior CAR-T cell therapy or prior BCMA-targeted therapy. Examples of BCMA-targeted therapy include teclistamab and elranatamab.

    Only one idecabtagene vicleucel treatment per lifetime is considered medically necessary. Repeat administration after the lifetime treatment has been used is considered experimental and investigational because the effectiveness of repeat treatment has not been established.

    Use of idecabtagene vicleucel for indications other than relapsed or refractory multiple myeloma is considered experimental and investigational because the effectiveness of treatment for other indications has not been established.

    Billing and Diagnosis Codes

    CPT CodesCPTCovered
    38225Chimeric antigen receptor T-cell (CAR-T) therapy; harvest of blood-derived T lymphocytes for development of genetically modified autologous CAR-T cells, per day
    38226Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for transportation (e.g., cryopreservation, storage)
    38227Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preservation of CAR-T cells for administration
    38228Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration, autologous
    Q2055Idecabtagene vicleucel, up to 510 million autologous B-cell maturation
    HCPCS CodesHCPCSCovered
    Q2055Idecabtagene vicleucel, up to 510 million autologous B-cell maturation antigen (BCMA) directed CAR-positive T-cells, including leukapheresis and dose preparation procedures, per therapeutic dose.
    ICD-10 CodesICD-10
    C90.00Multiple myeloma not having achieved remission
    C90.01Multiple myeloma in remission
    C90.02Multiple myeloma in relapse
    Z51.12Encounter for antineoplastic immunotherapy
    ICD-10 Not coveredICD-10Not Covered
    No codes listed

    Authorization and Documentation Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for idecabtagene vicleucel (Abecma®). All requests are reviewed by a clinical pharmacist and medical director.

    Documentation Required

    Clinical Eligibility Documentation

    Submit documentation showing that the member meets all medical-necessity criteria for idecabtagene vicleucel, including diagnosis, age, specialist involvement, FDA-labeled dosing, monotherapy use, performance status, organ function, and apheresis candidacy.

    • Relapsed or refractory multiple myeloma
    • Age 18 years or older
    • Prescribed by or used in consultation with a board-certified hematologist or oncologist
    • Dosed and administered according to FDA-approved labeling and used as monotherapy
    • ECOG performance status of 0 or 1

    Therapy Overview

    Idecabtagene vicleucel (Abecma) is a BCMA-directed autologous chimeric antigen receptor T-cell therapy for adults with relapsed or refractory multiple myeloma after at least two prior lines of therapy, including an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 monoclonal antibody. CAR-T treatment involves collecting and genetically modifying the member’s T cells, followed by reinfusion to produce a targeted antitumor response. Treatment is associated with risks including cytokine release syndrome, neurologic toxicities such as ICANS, cytopenias, infections, prolonged cytopenias, and secondary malignancies; specialized monitoring and multidisciplinary management are required.

    Clinical Definitions

    Chimeric antigen receptor (CAR) T-cell therapy
    DefinitionAn autologous immunotherapy in which a patient's T cells are collected, genetically modified to target cancer cells, and reinfused to produce a targeted antitumor response.
    Treatment processThe patient's T cells are collected and genetically modified to target cancer cells before being reinfused.
    Primary useCAR T-cell therapies are primarily used to treat hematologic malignancies.
    Multiple myeloma
    DefinitionMultiple myeloma is a cancer of plasma cells in the bone marrow that leads to production of abnormal proteins and organ damage.
    Disease courseMultiple myeloma remains an incurable disease despite advances in treatment, and most patients eventually relapse.

    Initial Treatment for Relapsed or Refractory Multiple Myeloma

    Lifetime Quantity Limit

    Idecabtagene vicleucel (Abecma)
    Lifetime limitOnly one treatment per lifetime is considered medically necessary.
    Repeat administrationRepeat administration of idecabtagene vicleucel (Abecma) is considered experimental and investigational.
    Policy rationaleThe effectiveness of repeat administration has not been established.

    Administration Setting

    Billing Rule

    Coordinate administration at a specialized center

    Coordinate administration through a specialized treatment center with established protocols for adverse-event monitoring, early intervention, and multidisciplinary care. Administration requires monitoring and management of complex immune-mediated adverse events, including ICANS.

    • Coordinate care across specialized treatment centers
    • Use established adverse-event monitoring and early-intervention protocols
    • Ensure multidisciplinary management and ongoing monitoring
    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyIdecabtagene vicleucel (Abecma) Coverage
    Policy CodePolicy 290
    Change TypeRevised
    Effective DateAug 1, 2026
    Last ReviewJun 25, 2026
    Next Review DateJun 25, 2027
    Key ActionSubmit prior authorization documentation showing that all medical-necessity criteria are met.
    SourceLink
    On This Page
    Coverage Criteria and ExclusionsBilling and Diagnosis CodesAuthorization and Documentation RequirementsTherapy OverviewClinical DefinitionsInitial Treatment for Relapsed or Refractory Multiple MyelomaLifetime Quantity LimitAdministration Setting
  1. Adequate bone marrow, renal, hepatic, and cardiac function
  2. Assessed by a hematologist/oncologist as an appropriate candidate for apheresis
    3. Documentation Required

    Prior Therapy Documentation

    Document relapsed or refractory disease and receipt of at least two prior lines of systemic therapy, including the required therapy classes.

    • Immunomodulatory agent, such as lenalidomide, pomalidomide, or thalidomide
    • Proteasome inhibitor, such as bortezomib, carfilzomib, or ixazomib
    • Anti-CD38 monoclonal antibody, such as daratumumab, elotuzumab, or isatuximab
    Denial Risk

    Exclusion Screening

    Screen and document the absence of prior treatments and clinical conditions that exclude coverage.

    • No previous CAR-T cell therapy
    • No prior B-cell maturation antigen (BCMA)-targeted therapy, such as teclistamab or elranatamab
    • No active infection, including hepatitis B, hepatitis C, or HIV infection
    • No inflammatory disorder
    • No history of allogeneic stem cell transplant
    • No autologous stem cell transplant within 12 weeks before apheresis
    • No known active or prior central nervous system involvement, or clinical signs of meningeal involvement, from multiple myeloma
    Denial Risk

    Repeat Treatment Not Covered

    Only one idecabtagene vicleucel treatment per lifetime is considered medically necessary. Repeat administration is experimental and investigational because its effectiveness has not been established.

    Denial Risk

    Other Indications Not Covered

    Use of idecabtagene vicleucel for indications other than relapsed or refractory multiple myeloma is experimental and investigational because its effectiveness has not been established.

    Denial Risk

    Failure to Meet Medical-Necessity Criteria

    Requests may be denied when required medical-necessity criteria or supporting documentation are missing, incomplete, or not met.

    • Document all clinical eligibility criteria before submission.
    • Document at least two prior systemic therapy lines and the required immunomodulatory agent, proteasome inhibitor, and anti-CD38 monoclonal antibody classes.
    • Document exclusion screening, including prior CAR-T or BCMA-targeted therapy and the listed infection, inflammatory, transplant, and central nervous system exclusions.
    Treatment contextPatients who relapse commonly require additional lines of therapy; idecabtagene vicleucel is indicated for adults with relapsed or refractory multiple myeloma after two or more prior lines of therapy.
    BCMA
    MeaningBCMA stands for B-cell maturation antigen.
    Therapeutic roleBCMA is the target of idecabtagene vicleucel.
    Treatment relationshipIdecabtagene vicleucel (Abecma) is a BCMA-directed CAR T-cell therapy.