Medicare AdvantagePrior AuthMedium impact
Adcetris® (brentuximab vedotin) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Apr 22, 2026
We identified it
Aug 11, 2026
Summary
Humana revised its prior authorization policy for Adcetris® (brentuximab vedotin) effective April 22, 2026, clarifying coverage criteria across seven distinct lymphoma indications for Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). Key changes include specific eligibility requirements for each indication, documented exclusions for disease progression on prior Adcetris therapy, and standardized 6-month approval/renewal periods. Billing teams must implement prior authorization triggers for all Adcetris claims under these plans.
Action Required
By April 22, 2026: Billing team must implement prior authorization requirements for HCPCS code J9041 (brentuximab vedotin injection) for all Medicare Advantage and Medicaid claims (FL, KY, SC). Action items: (1) Update billing system to require prior auth submission before claim processing for J9041; (2) Create submission checklist documenting which of the seven indications applies and verifying member meets ALL listed criteria for that indication; (3) Train billing staff and providers that claims will be DENIED without prior auth approval; (4) Configure system to flag any claims showing disease progression on prior Adcetris for manual review before denial; (5) Implement 6-month renewal tracking in billing system for all approved cases. Providers must document indication (HL previously untreated, HL relapsed/refractory, HL consolidation, LBCL, sALCL/PTCL previously untreated, sALCL relapsed/refractory, or pcALCL/MF) and supporting clinical criteria on all Adcetris requests before submission to payers.