Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Food and Drug Administration (FDA) Indications:
The use of bendamustine (Treanda, Bendeka, Belrapzo) may be considered medically necessary for the following conditions:
Chronic Lymphocytic Leukemia (CLL)
- As treatment of individuals with CLL; or
Non-Hodgkin Lymphoma (NHL)
- Indolent B-cell NHL as therapy that has progressed during or within six months of treatment with rituximab or a rituximab-containing regimen.
The use of bendamustine (Treanda, Bendeka, Belrapzo) for all other indications is considered experimental/investigational, and therefore, non-covered. Scientific evidence does not support its use for any other indication.
Procedure Codes
