Medicare AdvantagePrior AuthHigh impact
Bendamustine products (Treanda, Bendeka, Belrapzo, Vivimusta) (Revised)
Humana·FL, KY, SC, VA · Hematology, Oncology, Pharmacy·Medicaid
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
This revised Humana policy (effective January 1, 2023, revised February 25, 2026) establishes prior authorization requirements for bendamustine products across five covered indications: CLL, Multiple Myeloma, Hodgkin Lymphoma, Non-Hodgkin's Lymphoma, and Waldenström's Macroglobulinemia. The policy specifies strict clinical criteria for each indication and excludes members experiencing disease progression on bendamustine-containing regimens. All bendamustine prescriptions require prior authorization approval for plan year duration.
Action Required
By March 15, 2026 (before next plan year renewal): (1) Billing team must configure prior authorization requirements in billing software for all bendamustine products (Treanda, Bendeka, Belrapzo, Vivimusta) across Humana Medicare Advantage and Medicaid plans in FL, KY, SC, and VA. (2) Providers must be educated that ALL bendamustine claims require prior authorization documentation including: specific diagnosis (CLL, MM, HL, NHL subtypes, or Waldenström's), disease status (first-line, relapsed, refractory, or progressive), and confirmation member has not experienced prior disease progression on bendamustine regimens. (3) Update encounter forms and EMR templates to include checkboxes for required clinical criteria. (4) Front desk staff must flag all bendamustine orders for prior auth submission before dispensing. (5) Claims submitted without prior authorization or failing to meet policy criteria will be denied; resubmission with proper authorization required to avoid payment delays.