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 for treatment of any of the current category 1 or 2A NCCN recommendations.
Loncastuximab tesirine-lpyl (Zynlonta) may be considered medically necessary in individuals 18 years and older for the following:
Large B-Cell Lymphoma
- As treatment of individuals with 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) with disease progression on or after two (2) or more different lines of chemotherapy.
Loncastuximab tesirine-lpyl (Zynlonta) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.