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.
Mosunetuzumab-axgb (Lunsumio) may be considered medically necessary in individuals 18 years and older when ALL of the following criteria are met:
Follicular Lymphoma
- Individual has a diagnosis of relapsed or refractory follicular lymphoma; and
- Individual has received two (2) or more lines of systemic therapy; or
Compendia Sources
Mosunetuzumab-axgb (Lunsumio) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of mosunetuzumab-axgb (Lunsumio) 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
