Medicare AdvantagePrior AuthMedium impact
Zynlonta™ (loncastuximab tesirine-Ipyl) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jun 24, 2026
We identified it
Jul 2, 2026
Summary
This is a revised Humana pharmacy coverage policy for Zynlonta (loncastuximab tesirine-Ipyl) effective June 24, 2026, establishing prior authorization requirements for this drug across Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina. The policy requires patients to have relapsed/refractory B-cell lymphoma, at least two prior lines of systemic therapy, and use Zynlonta as a single agent. Claims will be denied if the patient has experienced disease progression on Zynlonta or does not meet all four coverage criteria.
Action Required
By June 24, 2026: (1) Billing team must implement prior authorization requirement in billing system for all Zynlonta claims across affected plans (Medicare, FL Medicaid, KY Medicaid, SC Medicaid). (2) Update claim submission workflows to require documentation of diagnosis (DLBCL or HGBL), relapsed/refractory status, confirmation of ≥2 prior systemic therapy lines, and single-agent use before claim submission. (3) Configure system to automatically deny claims if patient has prior disease progression on Zynlonta. (4) Clinical/coding staff must verify all four coverage criteria are met before authorizing treatment. (5) Providers must be notified of new prior authorization requirement through provider bulletins. Non-compliance will result in claim denials and delayed patient access to approved therapy.