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AetnaCommercial · Coverage · Medical Policy · Hematology, OncologyMedium impact

Belinostat (Beleodaq) (CPB 0887, reviewed 2025-12-09)

Effective date
Not stated in the notice
Identified
Aug 12, 2026

Summary

Aetna considers belinostat (Beleodaq) medically necessary for commercial plans as a single agent in these cases: peripheral T-cell lymphoma that is relapsed or refractory or used for palliative intent, hepatosplenic T-cell lymphoma after two or more previous lines of chemotherapy, relapsed or refractory extranodal NK/T-cell lymphoma with an inadequate response or contraindication to asparaginase-based therapy, and adult T-cell leukemia/lymphoma or breast implant-associated anaplastic large cell lymphoma used for subsequent therapy. Aetna considers belinostat experimental, investigational, or unproven for all other indications, including B-cell lymphomas, Hodgkin lymphoma, and multiple myeloma, and for concomitant use with Folotyn (pralatrexate), Istodax (romidepsin), Ninlaro (ixazomib), or Zolinza (vorinostat). Continuation of belinostat is medically necessary for a listed indication when there is no evidence of unacceptable toxicity or disease progression on the current regimen.

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What to do

Action · 7 steps
01REQUIREMENTS: Billing team: when billing belinostat (Beleodaq) for commercial members, confirm the request matches a listed indication and its criteria.
02For peripheral T-cell lymphoma, the drug must be used for relapsed or refractory disease or for palliative intent.
03For hepatosplenic T-cell lymphoma, the member must have had two or more previous lines of chemotherapy.
04For extranodal NK/T-cell lymphoma, the member must have an inadequate response or contraindication to asparaginase-based therapy, such as pegaspargase.
05For adult T-cell leukemia/lymphoma and breast implant-associated anaplastic large cell lymphoma, the drug must be used for subsequent therapy.
06For continuation requests, confirm there is no evidence of unacceptable toxicity or disease progression on the current regimen.
07Concomitant use with Folotyn, Istodax, Ninlaro, or Zolinza is experimental, investigational, or unproven under this policy, so claims for those combinations are not covered.

Codes mentioned

J903296413C82.00C82.99C84.40C84.60C84.69C84.70C84.7AC86.00C86.01C86.10C86.11C86.20C86.21C86.50C86.51C91.50C91.52

Original notice

Belinostat (Beleodaq) (CPB 0887, reviewed 2025-12-09)
aetna.com · Always check the source before changing claims.
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