Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the
www.fepblue.org
website.
Loncastuximab tesirine-lpyl (Zynlonta) may be considered medically necessary in individuals 18 years and older when the following criteria are met:
-
Individual has relapsed or refractory large B cell lymphoma (e.g., diffuse large B-cell lymphoma not otherwise specified, diffuse large B-cell lymphoma arising from low grade lymphoma, high-grade-B-cell lymphoma);
and
-
Individual has had disease progression on or after two (2) or more different lines of chemotherapy;
or
Compendia Sources
Loncastuximab tesirine-lpyl (Zynlonta) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of loncastuximab tesirine-lpyl (Zynlonta) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Code
