Zynlonta™ (loncastuximab tesirine-Ipyl) (New)

By September 1, 2026: Billing team must implement prior authorization process for all Zynlonta claims in Ohio Medicaid. (1) Update billing system to flag Zynlonta prescriptions for prior auth review. (2) Create verification checklist for claims submission: confirm patient has diagnosis of DLBCL (not otherwise specified OR arising from low-grade lymphoma) OR HGBL with/without translocations; verify relapsed or refractory disease status; confirm 2+ prior lines of systemic therapy completed; confirm single-agent use (no combination therapy). (3) Do NOT submit claims if patient has documented disease progression on prior Zynlonta use (automatic exclusion). (4) Providers must submit clinical documentation supporting all four criteria with prior authorization requests. (5) Obtain approval before dispensing; initial approval is for plan year duration or as determined by clinical review. Consequence: Claims submitted without prior authorization or missing clinical criteria will be denied by Humana Ohio Medicaid.