Medicare AdvantagePrior AuthHigh impact
Bendamustine products (Treanda, Bendeka, Belrapzo, Vivimusta) (Revised)
Humana·FL, KY, SC, VA · Oncology, Hematology, Pharmacy·Medicaid
Effective date
Jan 1, 2023
We identified it
Aug 12, 2026
Summary
This is a revised Humana prior authorization policy for bendamustine products (Treanda, Bendeka, Belrapzo, Vivimusta) effective January 1, 2023, with the most recent revision dated February 25, 2026. The policy establishes specific clinical criteria for coverage across five hematologic malignancies (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 eligible for coverage. Prior authorization is required for all bendamustine use across Medicare Advantage, Medicare Traditional, and four state Medicaid programs.
Action Required
IMMEDIATE: Billing team must implement prior authorization requirements for all bendamustine product claims (Treanda, Bendeka, Belrapzo, Vivimusta) in billing system. Before submitting claims: (1) Verify member diagnosis matches one of five covered conditions (CLL, Multiple Myeloma, Hodgkin Lymphoma, NHL, or Waldenström's Macroglobulinemia); (2) Confirm bendamustine use aligns with specific clinical criteria for each diagnosis (e.g., relapsed/refractory disease, first-line therapy where applicable); (3) Confirm member has NOT experienced prior disease progression on bendamustine regimens (Exclusion #1); (4) Submit prior authorization request via Humana's PAL system at www.humana.com/PAL before dispensing/administering drug. In billing software, flag all claims for HCPCS J9033 and J9034 to require prior auth approval documentation before processing. Failure to obtain prior authorization will result in claim denials. Update provider notices and encounter forms to remind oncology and hematology providers of authorization requirements. This policy applies to Medicare Advantage, Traditional Medicare, and Medicaid members in Florida, Kentucky, South Carolina, and Virginia.