BlueCross BlueShield of Tennessee Medical Policy Manual

Bendamustine HCl (Treanda®)

NDC CODE(S)

63459-0390-xx Treanda 25 MG SOLR (CEPHALON)

 

63459-0391-xx Treanda 100 MG SOLR (CEPHALON)

DESCRIPTION

Bendamustine, classified as a bifunctional alkylating agent, is a nitrogen mustard analogue.  It is an antineoplastic agent whose exact mechanism of action is unknown.  As an alkylating agent it interferes with DNA replication and the transcription of RNA which ultimately disrupts nucleic acid function.  In this respect, bendamustine has produced more DNA double-strand breaks than other alkylating agents.  It may also activate apoptosis by inhibiting mitosis, with DNA-damaged cells undergoing a premature form of necrotic cell death known as mitotic catastrophe.

REFER TO DECISION SUPPORT TREE

POLICY

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

RENEWAL CRITERIA

INDICATION(S) DOSAGE & ADMINISTRATION
NHL Up to 120mg/m² on days 1 and 2 of a 21 day cycle up to 8 cycles
All other indications Up to 100mg/m² on days 1 and 2 of a 28 day cycle up to 6 cycles

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.

IMPORTANT REMINDER

We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION 

For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).

No controlled studies were found in the published literature that validate the use of bendamustine HCl (Treanda®) for the treatment of other conditions or diseases.

SOURCES

Lexi-Comp Online. (2017, March). AHFS DI. Bendamustine hydrochloride. Retrieved March 24, 2017 from Lexi-Comp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Drug Evaluations. (2017, March). Bendamustine. Retrieved March 24, 2017 from MICROMEDEX Healthcare Series.

National Comprehensive Cancer Network. (2017). NCCN Drugs & Biologics Compendium®. Bendamustine hydrochloride. Retrieved March 24, 2017 from the National Comprehensive Cancer Network.

U. S. Food and Drug Administration. (2016, October). Center for Drug Evaluation and Research. Treanda® bendamustine hydrochloride. Retrieved March 24, 2017 from http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/022249s022lbl.pdf.

ORIGINAL EFFECTIVE DATE:  3/12/2009

MOST RECENT REVIEW DATE:  6/6/2017

ID_MRx

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

Pharmaceutical Decision Support Tree

Bendamustine (Treanda®)

  1. Is this the initial request for bendamustine HCl (Treanda®)?

If yes, go to question #2

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Is the individual 18 years of age or older with no prior treatment with bendamustine?

If yes, go to question #3

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Does the individual have a diagnosis of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)?

If yes, go to question #18

If no, go to question #4

  1. Does the individual have a diagnosis of Waldenström’s macroglobulinemia/Lymphoplasmacytic lymphoma?

If yes, go to question #18

If no, go to question #5

  1. Does the individual have a diagnosis of Hodgkin lymphoma further diagnosed as classical Hodgkin lymphoma for use as ANY ONE of the following?

If yes, go to question #18

If no, go to question #6

  1. Does the individual have a diagnosis of Multiple myeloma, previously treated, in relapsed, refractory or progressive disease as ANY ONE of the following?

If yes, go to question #18

If no, go to question #7

  1. Does the individual have a diagnosis of Non-Hodgkin lymphoma further diagnosed as Adult T-cell leukemia/lymphoma as a single agent for second line or later therapy?

If yes, go to question #18

If no, go to question #8

  1. Does the individual have a diagnosis of Non-Hodgkin lymphoma further diagnosed as AIDS-Related B-Cell Lymphoma as second-line or subsequent therapy in a noncandidate for high-dose therapy, with or without rituximab?

If yes, go to question #18

If no, go to question #9

  1. Does the individual have a diagnosis of Non-Hodgkin lymphoma further diagnosed as Diffuse Large B-Cell Lymphoma as second-line or subsequent therapy in a noncandidate for high-dose therapy, with or without rituximab?

If yes, go to question #18

If no, go to question #10

  1. Does the individual have a diagnosis of Non-Hodgkin lymphoma further diagnosed as Follicular Lymphoma and / or Nodal Marginal Zone Lymphoma as first-line therapy in combination with rituximab OR as second-line or subsequent therapy as a single agent or in combination with rituximab or obinutuzumab?

If yes, go to question #18

If no, go to question #11

  1. Does the individual have a diagnosis of Non-Hodgkin lymphoma further diagnosed as Gastric MALT lymphoma as first-line or additional therapy in combination with rituximab OR second-line or subsequent therapy for recurrent or progressive disease with or without rituximab or obinutuzumab?

If yes, go to question #18

If no, go to question #12

  1. Does the individual have a diagnosis of Non-Hodgkin lymphoma further diagnosed as Mantle Cell Lymphoma Induction therapy with first line in combination with rituximab OR for second-line subsequent therapy for relapsed, refractory or progressive disease, as a single agent or in combination with rituximab?

If yes, go to question #18

If no, go to question #13

  1. Does the individual have a diagnosis of Non-Hodgkin lymphoma further diagnosed as Mycosis Fungoides (MF)/Sézary Syndrome (SS) as single-agent therapy?

If yes, go to question #18

If no, go to question #14

  1. Does the individual have a diagnosis of Non-Hodgkin lymphoma further diagnosed as Nongastric MALT lymphoma as first-line therapy with rituximab OR as second-line or subsequent therapy as a single agent or in combination with rituximab or obinutuzumab?

If yes, go to question #18

If no, go to question #15

  1. Does the individual have a diagnosis of Non-Hodgkin lymphoma further diagnosed as Peripheral T-cell lymphoma as second-line or subsequent therapy for relapsed or refractory disease?

If yes, go to question #18

If no, go to question #16

  1. Does the individual have a diagnosis of Non-Hodgkin lymphoma further diagnosed as Primary cutaneous B-cell lymphoma used for first-line therapy in combination with rituximab OR second-line or subsequent therapy with or without rituximab or obinutuzumab in noncandidate for high-dose therapy?

If yes, go to question #18

If no, go to question #17

  1. Does the individual have a diagnosis of Non-Hodgkin lymphoma further diagnosed as Splenic marginal zone lymphoma as first-line therapy or in combination with rituximab OR as second-line or subsequent therapy as a single agent or in combination with rituximab or obinutuzumab?

If yes, go to question #18

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Is the request for 600 billable units or less every 21 days for NHL diagnoses or 500 billable units or less every 28 days for all other indications for six months ONLY?

If yes, go to question #19

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Is the dosage requested ANY ONE of the following?

If yes, this satisfies medical necessity and medical appropriateness criteria

If no, this does not meet medical necessity and/or medical appropriateness criteria

This document has been classified as public information.