Medicare AdvantagePrior AuthMedium impact
Zynlonta™ (loncastuximab tesirine-Ipyl) (Revised)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Jul 21, 2021
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage revised its Zynlonta (loncastuximab tesirine-Ipyl) coverage policy on June 25, 2025. The policy maintains prior authorization requirements for this CD19-directed antibody used to treat relapsed/refractory large B-cell lymphoma in patients who have received 2+ prior systemic therapies. Key criteria include diagnosis confirmation (DLBCL or HGBL), relapsed/refractory disease status, and single-agent use. Claims will be denied without prior authorization and if patients have experienced disease progression on Zynlonta.
Action Required
Before submitting any Zynlonta claims to Humana Medicare Advantage: (1) Billing team must implement prior authorization workflow requiring submission before drug administration; (2) Verify patient meets ALL four approval criteria: DLBCL/HGBL diagnosis, relapsed/refractory disease, ≥2 prior systemic therapy lines, and single-agent use; (3) Check exclusion criteria—deny internal requests if patient has prior disease progression on Zynlonta; (4) Update oncology department encounter templates to document diagnosis type, prior therapy count, and treatment line status; (5) Reference Humana's Preauthorization and Notification List (PAL) at www.humana.com/PAL for medically billed claim codes; (6) Communicate with oncology providers that coverage continues until progressive disease or unacceptable toxicity per plan year duration. Without prior authorization, Humana will deny claims. Document all four approval criteria in patient record before submission.