Aetna's Clinical Policy Bulletin 0875 covers bendamustine products (Belrapzo, Bendeka, Treanda, Vivimusta and generic bendamustine) for commercial medical plans, and precertification is required for these products in applicable plan designs. Aetna considers bendamustine medically necessary for the listed indications when the stated criteria are met, including chronic lymphocytic leukemia/small lymphocytic leukemia, several B-cell and T-cell lymphomas, multiple myeloma, classic Hodgkin lymphoma, Waldenstrom macroglobulinemia, systemic light chain amyloidosis, autologous transplant conditioning and cold agglutinin disease. Aetna considers all other indications experimental, investigational, or unproven, including breast cancer, colorectal cancer, melanoma and non-small cell lung cancer.
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01Billing team: Get precertification before scheduling bendamustine (Belrapzo, Bendeka, Treanda, Vivimusta or generic bendamustine) by calling (866) 752-7021 or faxing (888) 267-3277, and use the Statement of Medical Necessity forms under Specialty Pharmacy Precertification where needed.
02Providers: Make sure the requested indication meets the criteria in the Criteria for Initial Approval section, including the required combination drugs and treatment line for that indication.
03Billing team: For commercial plans, check the preferred drug list in the Aetna Commercial Clinical Program Summary, because Aetna may require a trial of a lower-cost drug in the same therapeutic class before coverage is granted for a higher-cost drug.
04Billing team: Bill HCPCS J9033 (Treanda), J9034 (Bendeka), J9036 (Belrapzo or generic bendamustine) or J9056 (Vivimusta), each per 1 mg, only when the selection criteria are met.
Summaries are AI-assisted. Always confirm against the original payer notice.
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