MedicaidPrior AuthHigh impact
Bendamustine products (Treanda, Bendeka, Belrapzo, Vivimusta)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
May 1, 2026
We identified it
Aug 12, 2026
Summary
Humana Medicaid (Ohio) implemented a new prior authorization policy effective May 1, 2026 for all bendamustine products (Treanda, Bendeka, Belrapzo, Vivimusta) covering five indications: CLL, Multiple Myeloma, Hodgkin Lymphoma, Non-Hodgkin's Lymphoma, and Waldenström's Macroglobulinemia. The policy specifies strict clinical criteria for each indication and automatically denies coverage if members experience disease progression on bendamustine-containing regimens.
Action Required
By April 15, 2026: Billing team must update all prior authorization workflows and billing software to require mandatory prior auth submission for bendamustine products (J9033, J9034) for all Humana Medicaid Ohio members. Providers and clinical staff must verify patient meets ONE of five specific diagnosis/treatment criteria before treatment initiation: (1) CLL as first-line or relapsed/refractory, (2) Multiple Myeloma for relapse/progressive/refractory disease, (3) Classical Hodgkin Lymphoma as subsequent therapy for relapsed/refractory disease, (4) One of six specific NHL subtypes with defined line-of-therapy requirements, or (5) Waldenström's Macroglobulinemia as primary or progressive/relapsed disease. MANDATORY EXCLUSION: Do not approve any claims if member has disease progression on prior bendamustine regimens—this is an automatic denial trigger. Update encounter templates and prior auth submission forms in billing system to capture diagnosis, treatment line (first-line vs. relapsed/refractory), and prior bendamustine treatment history. Communicate requirements to all prescribers and infusion centers. Claims submitted without prior authorization or failing to meet clinical criteria will be denied by Humana.