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HumanaMedicaid · Prior Auth · Medicaid · IN · Oncology, Hematology, PharmacyMedium impact

Zynlonta™ (loncastuximab tesirine-Ipyl) (New)

Act
by Aug 31, 2026
Effective date
Sep 1, 2026
Identified
Sep 2, 2026

Summary

Humana Medicaid Indiana has issued a new prior authorization policy (effective September 1, 2026) for Zynlonta™ (loncastuximab tesirine-Ipyl), a CD19-directed antibody-alkylating agent conjugate for relapsed/refractory B-cell lymphomas. Billing teams must implement prior authorization requirements before dispensing this drug, ensuring patients meet strict clinical criteria: diagnosis of DLBCL or HGBL, relapsed/refractory disease, 2+ prior systemic therapy lines, and single-agent use. Claims submitted without prior authorization will be denied.

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What to do

by Aug 31, 2026 · 5 steps
01Billing team must update pharmacy billing system to flag Zynlonta (HCPCS J9313) as a PRIOR AUTHORIZATION REQUIRED drug for all Humana Medicaid Indiana members.
02Configure system to enforce clinical criteria verification before claim submission: member has DLBCL (not otherwise specified OR arising from low-grade lymphoma) OR HGBL; member has relapsed/refractory disease; member has received 2+ lines of prior systemic therapy; and Zynlonta is being used as single agent (no combination therapy).
03Pharmacy staff and billing team must reject claims if disease progression on Zynlonta is documented (Exclusion #1).
04Update prior authorization request template to capture required clinical documentation: diagnosis type, prior therapy lines, and disease status.
05Provider communication: send notice to all oncology providers and dispensing pharmacies that this is a new PA requirement effective immediately; include the clinical criteria checklist.
If missed: Failure to obtain prior authorization will result in claim denials from Humana Medicaid Indiana.

Codes mentioned

J9313

Original notice

Zynlonta™ (loncastuximab tesirine-Ipyl) (New)
mcp.humana.com · Always check the source before changing claims.
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Related policy hubs

Humana policiesIN policy changesOncologyHematologyPharmacyCode J9313

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