MedicaidPrior AuthHigh impact
Adcetris® (brentuximab vedotin)
Humana·OH · Hematology, Oncology·Medicaid
Effective date
Jul 1, 2026
We identified it
Aug 11, 2026
Summary
Humana Ohio Medicaid implemented a new prior authorization policy for Adcetris® (brentuximab vedotin) effective July 1, 2026, covering seven distinct lymphoma and T-cell lymphoma indications. The policy establishes specific clinical criteria, combination therapy requirements, and exclusions (including disease progression on Adcetris) for each indication, with 6-month initial and renewal approval periods.
Action Required
By June 15, 2026: Billing team and clinical staff must implement prior authorization requirements for all Adcetris (brentuximab vedotin) claims (HCPCS J9310) for Humana Ohio Medicaid members. Update billing system to flag all Adcetris requests for PA review before claim submission. Create clinical decision support checklist in EMR covering all seven indications with specific criteria: (1) Hodgkin lymphoma previously untreated - requires combination chemotherapy regimen; (2) Hodgkin lymphoma relapsed/refractory - requires monotherapy or supported combination, exclude if prior disease progression on Adcetris; (3) Hodgkin lymphoma consolidation - requires post-HSCT use with documented high-risk criteria; (4) LBCL relapsed/refractory - requires 2+ prior therapies, ineligibility for ASCT/CAR-T, combination with lenalidomide and rituximab product; (5) sALCL/CD30+ PTCL previously untreated - requires CD30 positivity documentation and cyclophosphamide/doxorubicin/prednisone combination; (6) sALCL relapsed/refractory - requires prior multi-agent progression, monotherapy, CD30 positivity; (7) pcALCL or CD30+ Mycosis Fungoides - requires prior systemic therapy and monotherapy use. Providers must submit prior auth requests with documentation supporting clinical criteria and disease staging before administration. Establish 6-month renewal reminder system in billing software. Communicate policy to all oncology and hematology providers. Claims submitted without completed prior authorization will be denied. Route all inquiries regarding PA status to clinical review team.