Medicare AdvantagePrior AuthMedium impact
Adcetris® (brentuximab vedotin) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Apr 22, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Adcetris® (brentuximab vedotin) prior authorization policy effective April 22, 2026, clarifying coverage criteria across seven lymphoma indications for Medicare and three Medicaid state programs (Florida, Kentucky, South Carolina). The policy maintains six-month initial and renewal approval durations with disease progression as a common exclusion criterion across all indications.
Action Required
By April 22, 2026: Billing and clinical teams must update prior authorization protocols in billing system and EMR templates to reflect revised Adcetris coverage criteria for all seven indications (Hodgkin lymphoma previously untreated/relapsed/consolidation, LBCL, sALCL previously untreated/relapsed, and pcALCL/MF). For each indication, ensure prior auth requests capture required documentation: disease diagnosis, treatment history (prior lines of therapy), planned regimen composition, CD30-positivity confirmation where applicable, and HSCT/CAR-T eligibility status for LBCL cases. Verify that system automatically denies or flags requests if member has documented disease progression while on Adcetris (applies to all indications except previously untreated scenarios). Update provider order entry systems to require selection of specific indication at time of order to trigger appropriate criteria checklist. Providers must obtain prior authorization before dispensing; claims submitted without prior auth approval will be denied. This applies only to Humana Medicare, Medicaid-FL, Medicaid-KY, and Medicaid-SC members.