CurrentAetnaPolicy N/A

Bortezomib (VELCADE) medication precertification request form

Precertification form and clinical information requirements for providers requesting authorization for bortezomib (VELCADE). Applicable to Aetna members; used to collect patient, prescriber, diagnosis, dosing and clinical justification for initiation or continuation of therapy.

Policy Summary

PayerAetna

PolicyBortezomib (VELCADE) medication precertification request form

Policy CodePolicy N/A

Change TypeInformational

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit the completed precertification form with all required clinical fields (including BSA, indication, dosing, dose thresholds, frequency, and combination therapy details) to Aetna Precertification Notification for review before initiation or continuation of bortezomib.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1precertification phone number listed

2fax numbers listed

7+diagnostic/place-in-therapy checkbox options shown

Precertification Submission Requirements

Precertification submission requirements

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ALL of the following

Patient identifying information (name, DOB, contact, weight, height, allergies)
Insurance information including Aetna member ID and other coverage
Prescriber information (name, credentials, address, phone, NPI, specialty)
Dispensing provider/administration information (place of administration, CPT administration codes if applicable, dispensing provider/pharmacy details)
Product information (requested agent: bortezomib / VELCADE; dose; frequency)
Primary and secondary ICD diagnosis codes
Clinical information: body surface area (BSA) must be provided
Clinical dosing thresholds documented: whether dose will exceed 1.6 mg/m2
Clinical dosing frequency threshold documented: whether more than 7 doses per 30-day period are required
Initiation request disease selection (any of the listed indications may be selected)
- Acute lymphoblastic leukemia
- Adult T-cell leukemia/lymphoma
- Follicular lymphoma
- Kaposi sarcoma
- Mantle cell lymphoma
- Multicentric Castleman disease
- Multiple myeloma
Therapy context/combination options
- Whether drug will be used as single agent (Yes/No)
- Whether drug will be used in combination with dexamethasone (Yes/No)
- Place in therapy: first-line or subsequent therapy
- Clinical setting: relapsed disease, refractory disease, or other
For continuation requests
- Documentation whether patient has experienced unacceptable toxicity or disease progression while on current regimen (Yes/No)

ALL of the following

Request type: indication of start of treatment (start date) or continuation of therapy (date of last treatment)
Precertification requester contact information (phone, fax)

ALL of the following

Acknowledgement/signature and date from the person completing the request
Note that incomplete or illegible submissions may delay review or result in denial; the plan may request additional information

What Providers Must Do

Prior Authorization

Precertification required

Submit the completed bortezomib (VELCADE) precertification form to Aetna Precertification Notification for review before initiating or continuing therapy. All fields must be completed and legible; contact phone and fax for Aetna Precertification Notification are provided on the form.

Documentation Required

Required clinical documentation

Include the patient’s BSA (m2); the indication selected from the listed diagnoses; dose and frequency; whether the dose will exceed 1.6 mg/m2; whether more than 7 doses per 30‑day period are required; whether the drug will be used as single agent or in combination with dexamethasone; place in therapy and clinical setting; and for continuation requests document unacceptable toxicity or disease progression on the current regimen.

Body surface area (BSA) in m2
Indication (select from listed diagnoses such as multiple myeloma, mantle cell lymphoma, POEMS, etc.)
Dose and dosing frequency
Will the patient's dose exceed 1.6 mg/m2? (Yes/No)
Does the patient require more than 7 doses per 30‑day period? (Yes/No)
Single agent vs. combination therapy (including whether used with dexamethasone)
Place in therapy (first‑line or subsequent) and clinical setting (relapsed, refractory, other)
For continuation: documentation of unacceptable toxicity or disease progression

Denial Risk

Incomplete submissions risk denial

The plan may request additional information or clarification; submissions with incomplete or illegible fields may delay review or result in denial of authorization.

Clinical and Administrative Context

Bortezomib (VELCADE) is an injectable proteasome inhibitor used to treat multiple hematologic malignancies and related disorders, including multiple myeloma and mantle cell lymphoma, among other listed indications. The precertification form identifies the requested product as bortezomib / VELCADE and must be completed and legible for review prior to initiation or continuation of therapy.

The form collects key clinical and administrative information to support determinations of medical necessity: patient identifiers and contact information, insurance and prescriber details, and dispensing/administration site and procedure codes. It also requires the Body Surface Area (BSA) in m2 to be provided for dose calculations, and asks whether the patient’s dose will exceed 1.6 mg/m2 and whether the patient requires more than 7 doses per 30-day period.

For initiation requests the form requires selection of the disease indication from a list that includes acute lymphoblastic leukemia, adult T‑cell leukemia/lymphoma, follicular lymphoma, Kaposi sarcoma, mantle cell lymphoma, multicentric Castleman disease, multiple myeloma, pediatric Classic Hodgkin lymphoma, antibody‑mediated rejection of solid organ, POEMS syndrome, systemic light chain amyloidosis, and Waldenström macroglobulinemia/lymphoplasmacytic lymphoma. The form also captures whether bortezomib will be used as a single agent or in combination (for example with dexamethasone), the place in therapy (first‑line or subsequent), and the clinical setting (relapsed, refractory, or other).

For continuation requests the form asks for documentation of whether the patient has experienced unacceptable toxicity or disease progression while on the current regimen. Providers must submit the completed precertification form, including dosing (dose and frequency), indication, BSA, combination therapy details, and relevant administration codes, to Aetna Precertification Notification using the contact numbers and fax listed on the form.

Policy Summary

PayerAetna

PolicyBortezomib (VELCADE) medication precertification request form

Policy CodePolicy N/A

Change TypeInformational

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Bortezomib (VELCADE) medication precertification request form

Precertification Submission Requirements

What Providers Must Do

Requested Codes on Form

Key Numeric / Clinical Thresholds

Clinical and Administrative Context

Defined Terms

Policy Update Changes