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AetnaCommercial · Prior Auth · Medical Policy · Oncology, HematologyMedium impact

Brentuximab Vedotin (Adcetris) (CPB 0823, reviewed 2026-09-24)

Effective date
Not stated in the notice
Identified
Sep 29, 2026

Summary

Aetna considers brentuximab vedotin (Adcetris) medically necessary for commercial medical plans when the request meets one of the listed uses. Listed uses include classic Hodgkin lymphoma as a single agent or in named combinations, relapsed or refractory DLBCL, HGBL and histologic transformation of indolent lymphoma, pediatric primary mediastinal large B-cell lymphoma with nivolumab or pembrolizumab, several CD30-positive T-cell lymphomas and primary cutaneous lymphomas. Reauthorization is considered medically necessary for a listed indication when there is no evidence of unacceptable toxicity or disease progression, and all other indications are considered experimental, investigational, or unproven.

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What to do

Action · 6 steps
01Billing team: precertification of brentuximab vedotin (Adcetris) is required of all Aetna participating providers and members in applicable plan designs.
02Request it by calling (866) 752-7021 or faxing (888) 267-3277.
03Statement of Medical Necessity forms are on the Specialty Pharmacy Precertification page.
04Billing team: review the Utilization Management Policy on Site of Care for Specialty Drug Infusions for the site of service.
05Billing team: HCPCS J9042 is covered when the selection criteria are met, and approvals may be subject to dosing limits in line with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines (see Medical Specialty Medication Quantity Limits).
06Uses outside the listed criteria are considered experimental, investigational, or unproven.

Codes mentioned

J9042C81.00C81.9AC82.00C82.8AC82.90C82.9AC84.A0C84.9AC84.AAC84.Z0C84.ZAC85.10C85.9AC83.00C83.0AC83.80C83.9AC86.50C86.51C83.30C83.3AC84.00C84.0AC84.10C84.1AC84.40C84.4AC84.60C84.7BC85.20C85.2AC86.00C86.01C86.10C86.60C86.61C88.40C88.41C91.10C91.12C91.40C91.42C91.50C91.52C91.Z0C91.Z2D47.Z1R59.0R59.9

Original notice

Brentuximab Vedotin (Adcetris) (CPB 0823, reviewed 2026-09-24)
aetna.com · Always check the source before changing claims.
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Related changes

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Related policy hubs

Aetna policiesOncologyHematologyCode J9042Code C81.00Code C81.9ACode C82.00Code C82.8ACode C82.90Code C82.9ACode C84.A0Code C84.9ACode C84.AACode C84.Z0Code C84.ZACode C85.10Code C85.9ACode C83.00Code C83.0ACode C83.80Code C83.9ACode C86.50Code C86.51Code C83.30Code C83.3ACode C84.00Code C84.0ACode C84.10Code C84.1ACode C84.40Code C84.4ACode C84.60Code C84.7BCode C85.20Code C85.2ACode C86.00Code C86.01Code C86.10Code C86.60Code C86.61Code C88.40Code C88.41Code C91.10Code C91.12Code C91.40Code C91.42Code C91.50Code C91.52Code C91.Z0Code C91.Z2Code D47.Z1Code R59.0Code R59.9

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