Medicare AdvantagePrior AuthMedium impact
Lynozyfic (linvoseltamab-gcpt) (Revised)
Humana·KY, SC · Oncology, Hematology·Medicaid
Effective date
Sep 24, 2025
We identified it
Jul 21, 2026
Summary
Humana revised its prior authorization policy for Lynozyfic (linvoseltamab-gcpt), a bispecific antibody for relapsed/refractory multiple myeloma. The policy requires prior auth approval for Medicare and Medicaid (Kentucky and South Carolina only) members meeting strict criteria: diagnosis of multiple myeloma with relapsed/refractory disease, at least four prior lines of therapy including specific drug classes, and single-agent use only. Members with prior disease progression on BCMA-directed CD3 T-cell engagers are excluded from coverage.
Action Required
By September 24, 2025: Billing team must implement prior authorization requirements for Lynozyfic in the billing system for Medicare Advantage and Medicaid members in Kentucky and South Carolina only. (1) Update prior auth triggers to require approval before claims submission for this drug. (2) Verify member eligibility against the four criteria: multiple myeloma diagnosis, relapsed/refractory disease status, documentation of at least four prior therapy lines (proteasome inhibitor, immunomodulatory agent, anti-CD38 monoclonal antibody confirmed), and single-agent use. (3) Screen for the exclusion criterion: no prior disease progression on BCMA-directed CD3 T-cell engager regimens. (4) Contact providers and pharmacy staff to communicate that Lynozyfic requires prior auth and that combination therapy is not covered (single agent only). (5) Establish workflow to verify REMS enrollment status, as the drug is available only through the Lynozyfic Risk Evaluation and Mitigation Strategy (REMS) program. Claims submitted without prior authorization will be denied. Update encounter templates and prior auth request forms to include the specific clinical criteria checklist.