ModifiedMass General Brigham Health PlanPolicy N/A

Lunsumio (mosunetuzumab-axgb)

Medical-benefit prior authorization policy for Lunsumio (mosunetuzumab-axgb) for treatment of adult patients with relapsed or refractory follicular lymphoma; defines clinical criteria, prescriber requirements, approval durations, and reauthorization considerations.

Policy Summary

PayerMass General Brigham Health Plan (MassHealth)

PolicyLunsumio (mosunetuzumab-axgb)

Policy CodePolicy N/A

Change TypeModified (P&T review)

Effective DateJun 1, 2025

Next Review Date

Key ActionSubmit prior authorization requests under the medical benefit with documentation of diagnosis, prior systemic therapies (including at least one anti-CD20 agent), prescriber specialty, age, and dosing per labeling.

SourceLink

POLICY UPDATE CHANGES

Initial approval duration increased to 12 months.

Updated language of trials from '≥2 lines of systemic therapies' to indicating just '2' lines.

Updated formatting and references.

Policy created requiring PA through medical benefit.

2Required prior lines of therapy

>=18Minimum age (years)

17Max cycles with supporting data

12 months

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Coverage Summary

Surface thresholds and key policy stats

Minimum age>=18 years

Required prior lines of therapy2 lines including at least one anti-CD20 monoclonal antibody

Maximum supported cyclesNo data to support repeat dosing beyond 17 cycles

Initial approval duration12 months

Benefit and PAMedical-benefit prior authorization required (MassHealth)

Initial Therapy Criteria

Authorization Criteria (Initial)

Authorization may be granted when ALL of the following criteria are met, with documentation:

ALL of the following

Diagnosis of relapsed or refractory follicular lymphoma (FL)
Prescriber is a hematologist or oncologist
Dosing: Appropriate dosing
Policy references dosing per product labeling (see package insert)
Age: Member is ≥ 18 years of age on treatment date

Continuation / Members New to Plan

Authorization for members new to the plan

Authorization may be reviewed case-by-case for members currently receiving treatment with requested medication

ANY of the following

New to plan receiving therapy: Member is new to the plan and currently receiving Lunsumio
Excludes products obtained as samples or via manufacturer's patient assistance programs

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required through medical benefit

Prior authorization is required and managed as a medical-benefit prior authorization under MassHealth. Requests for members already receiving treatment may be reviewed on a case-by-case basis. Products obtained as samples or via manufacturer's patient assistance programs are excluded from coverage under this pathway.

Requests for members already receiving treatment are reviewed case-by-case.
Samples and manufacturer's patient-assistance program supplies are excluded.

Documentation Required

Documentation of prior therapies and prescriber specialty

Providers must document the diagnosis of relapsed or refractory follicular lymphoma, prior systemic therapies (including at least TWO lines of systemic therapy with at least one anti-CD20 monoclonal antibody), the prescriber's specialty (hematologist or oncologist), that the member is ≥18 years of age, and that dosing is consistent with product labeling.

Applicable Codes

Applicable program and benefitmixed

No codes listed

Clinical Evidence & References

Primary reference: Genentech Lunsumio package insert (2024 Dec).

Background clinical note: Lunsumio is an intravenous bispecific T-cell-redirecting antibody indicated for adult patients with relapsed or refractory follicular lymphoma after two or more lines of systemic therapy.

Background

Lunsumio (mosunetuzumab-axgb) is an intravenous bispecific T-cell-redirecting antibody indicated for adult patients with relapsed or refractory follicular lymphoma after two or more lines of systemic therapy. The policy manages coverage via a medical-benefit prior authorization program under MassHealth.

Definition — Anti-CD20 monoclonal antibody: Examples include rituximab and obinutuzumab; at least one must be included among prior systemic therapies.

Revision History

07/12/23added

Policy created; new drug Lunsumio (mosunetuzumab-axgb) will require prior authorization through the medical benefit. Effective 07/31/23.

05/15/25revised (non-clinical)

Non-clinical formatting and reference updates.

06/01/25revised (material)Latest