MedicaidPrior AuthHigh impact
Bendamustine products (Treanda, Bendeka, Belrapzo, Vivimusta) (Revised)
Humana·LA · Hematology, Oncology, Pharmacy·Medicaid
Effective date
Jan 1, 2026
We identified it
Aug 12, 2026
Summary
Humana Louisiana Medicaid updated its prior authorization policy for bendamustine products (Treanda, Bendeka, Belrapzo, Vivimusta) effective January 1, 2026, with a revision date of May 1, 2026. The policy establishes specific approval criteria for five indications (CLL, Multiple Myeloma, Hodgkin Lymphoma, Non-Hodgkin's Lymphoma, and Waldenström's Macroglobulinemia), with a universal exclusion: members experiencing disease progression on bendamustine-containing regimens are not approved. All bendamustine requests now require prior authorization before dispensing.
Action Required
Before January 1, 2026: (1) Billing team must implement prior authorization requirement in billing system for all bendamustine product claims (Treanda, Bendeka, Belrapzo, Vivimusta – HCPCS codes J9045, J9046, J9047, J9048) for Louisiana Medicaid members. (2) Update claim submission workflows to require prior auth clearance before processing. (3) Providers must document patient diagnosis (CLL, Multiple Myeloma, Hodgkin Lymphoma, Non-Hodgkin's Lymphoma subtype, or Waldenström's Macroglobulinemia) and treatment line (first-line, relapsed, refractory, progressive, or disease-specific criteria per policy) on all bendamustine requests. (4) Add hard stop in EMR/billing software to flag and reject any claims for members with prior history of disease progression on bendamustine. (5) Prior auth requests must reference specific policy criteria (Criteria #1 and #2 for applicable diagnosis). Claims submitted without prior authorization or lacking required clinical documentation will be denied. Renewal approvals are valid for plan year duration or as clinically determined.