CurrentAspirus ArisePolicy N/A

Adcetris (brentuximab) Utilization Management Medical Policy

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Defines authorization, dosing, and coverage criteria for Adcetris (brentuximab) for Aspirus Medicare plans, including FDA‑approved indications and recommended documentation/authorization processes for oncology providers.

Policy Summary

PayerAspirus Arise

PolicyAdcetris (brentuximab) Utilization Management Medical Policy

Policy CodePolicy N/A

Change TypeRevised dosing and indication placements

Effective DateJan 1, 2021

Last ReviewMar 18, 2026

Next Review DateMar 18, 2026

Key ActionObtain prior authorization with oncology specialist involvement and document that the patient meets indication-specific criteria and dosing limits.

SourceLink

POLICY UPDATE CHANGES

Hodgkin lymphoma dosing frequency was revised from no more frequently than once every 2 weeks to no more frequently than once weekly.

B‑Cell lymphoma condition of approval was moved from 'Other Uses with Supportive Evidence' to the 'FDA Approved Indications' section and the example list was revised (removed 'CD30+' qualifier and added histologic transformation to DLBCL).

Age requirement of ≥18 years for a B‑cell indication was removed.

T‑cell lymphoma examples were edited: some CD30+ entities removed from the Note and specific options (anaplastic large cell lymphoma; breast implant‑associated anaplastic large cell lymphoma; mycosis fungoides/Sezary syndrome) added as approval options.

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CurrentAspirus ArisePolicy N/A

Adcetris (brentuximab) Utilization Management Medical Policy

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Know when Aspirus Arise releases new policies or updates existing guidance.

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Policy Summary

PayerAspirus Arise

PolicyAdcetris (brentuximab) Utilization Management Medical Policy

Policy CodePolicy N/A

Change TypeRevised dosing and indication placements

Effective DateJan 1, 2021

Last ReviewMar 18, 2026

Next Review DateMar 18, 2026

Key ActionObtain prior authorization with oncology specialist involvement and document that the patient meets indication-specific criteria and dosing limits.

SourceLink

POLICY UPDATE CHANGES

Hodgkin lymphoma dosing frequency was revised from no more frequently than once every 2 weeks to no more frequently than once weekly.

Age requirement of ≥18 years for a B‑cell indication was removed.

Recommended Authorization Criteria

Coverage of Adcetris is not recommended for circumstances that are not explicitly listed in the Recommended Authorization Criteria. Criteria will be updated as new published data become available; requests for indications or uses outside the listed criteria should be expected to be denied or returned for additional information.

Any use of Adcetris outside the specific situations enumerated in the Recommended Authorization Criteria is not recommended for approval. Providers seeking coverage for off‑protocol or non‑listed uses should include supporting clinical evidence and understand that such requests may be declined.

Indication	Regimen / Dose	Frequency	Combination / Notes	Coverage status
B‑Cell lymphoma (examples: DLBCL, post‑transplant lymphoproliferative disorder, HIV‑related B‑cell lymphoma, high‑grade B‑cell lymphoma, primary mediastinal large B‑cell lymphoma, histologic transformation of indolent lymphoma to DLBCL)
Adcetris (brentuximab vedotin) 1.8 mg/kg IV (maximum 180 mg)
Every 3 weeks
Used in relapsed/refractory settings after at least one prior therapy; per FDA label, combined with lenalidomide and a rituximab product in specific large B‑cell lymphoma situations; prescribed by or in consultation with an oncologist

Billing and Dosing Codes

Relevant billing codes (not specified)mixed

NDC or specific HCPCS not listed

No explicit billing codes listed in document

Dose per administration — Adcetris

Dose per administration1.8 mg/kg per IV administration (maximum 180 mg)

Frequency (B-Cell & T-Cell indications)No more frequently than once every 3 weeks

Frequency (Hodgkin Lymphoma)No more frequently than once weekly

Prescriber and Authorization Requirements

Prior Authorization

Prior authorization required

Prior authorization is recommended for medical benefit coverage of Adcetris; approvals are provided for specified durations (typically 1 year) and require oncology specialist involvement. Extended approvals may be allowed if the patient continues to meet the Criteria and Dosing; requests for doses outside the established dosing will be reviewed case-by-case by a clinician.

Approvals are provided for the duration noted (typically 1 year).
Approval requires prescription by or in consultation with a physician who specializes in the condition being treated.
Requests for doses outside established dosing will be considered case-by-case by a clinician.

Step Therapy

Prior therapy required for B‑cell lymphoma

For B‑cell lymphoma approvals are contingent on the patient having tried at least one prior therapy (i.e., use as second‑line or subsequent therapy).

Authorized Line(s) of Therapy

Line of Therapy

Lines of therapy: Used as first-line in some T-cell and Hodgkin combinations; used as second-line or subsequent therapy in many B-cell and Hodgkin relapsed/refractory settings; specific prior-therapy requirement for B‑cell: at least one prior therapy.

Refer to indication-specific nodes for dosing frequency and authorization duration

Testing and Biomarker Criteria

CD30 — Biomarker requirement

BiomarkerCD30 expression (CD30+) is referenced as required or relevant for multiple T-cell and certain cutaneous lymphoma indications

Use in T-cell lymphoma examplesCD30+ angioimmunoblastic T-cell lymphoma, CD30+ peripheral T-cell lymphoma NOS, CD30+ primary cutaneous anaplastic large cell lymphoma, CD30+ lymphomatoid papulosis, CD30+ adult T-cell leukemia/lymphoma, CD30+ hepatosplenic T-cell lymphoma, CD30+ extranodal NK/T-cell lymphoma

Clinical relevanceCD30 status guides eligibility for certain Adcetris indications (document lists CD30-expressing and CD30+ disease among approval examples)

Drug and Term Definitions

Adcetris (brentuximab) — Definition

DrugAdcetris (brentuximab vedotin)

MechanismCD30-directed antibody–microtubule inhibitor conjugate

Indications (summary)Indicated for multiple Hodgkin, B-cell, and T-cell lymphoma uses including classical Hodgkin lymphoma, certain large B-cell lymphomas, primary cutaneous anaplastic large cell lymphoma, and systemic anaplastic large cell lymphoma

Clinical Background

Adcetris (brentuximab vedotin) is a CD30‑directed antibody‑drug conjugate that delivers a microtubule‑disrupting agent to CD30‑expressing cells. It is used across multiple lymphoma subtypes including classical Hodgkin lymphoma, certain B‑cell lymphomas, and a range of T‑cell and cutaneous T‑cell lymphomas. The agent is included in NCCN recommendations for several lymphoma indications and has demonstrated activity in relapsed/refractory settings in clinical studies. Authorization decisions follow indication‑specific criteria and dosing limits; when covered, dosing is typically 1.8 mg/kg (maximum 180 mg) per administration with frequency and combinations determined by the specific indication.