Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Brentuximab vedotin (Adcetris) may be considered medically necessary for ANY of the following conditions:
Classical Hodgkin Lymphoma (cHL)
- Treatment of individuals with previously untreated Stage III or IV cHL, in combination with doxorubicin, vinblastine, and dacarbazine; or
- Treatment of individuals with cHL at high risk of relapse or progression as post-autologous hematopoietic stem cell transplantation (auto-HSCT) consolidation; or
- Treatment of individuals with cHL after failure of auto-HSCT or after failure of at least two prior multi agent chemotherapy regimens in individuals who are not auto-HSCT candidates; or
Primary Cutaneous Anaplastic Large Cell Lymphoma (pcALCL)
- Treatment of individuals with pcALCL or CD30- expressing mycosis fungoides (MF) who have received prior systemic therapy; or
Systemic Anaplastic Large Cell Lymphoma (sALCL)
- Treatment of individuals with previously untreated sALCL or other CD30-expressing peripheral T-cell lymphomas (PTCL), including angioimmunoblastic T-cell lymphoma and PTCL not otherwise specified, in combination with cyclophosphamide, doxorubicin, and prednisone; or
- Treatment of individuals with sALCL after failure of at least one prior multi-agent chemotherapy regimen; or
Compendia Sources
Brentuximab vedotin (Adcetris) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of brentuximab vedotin (Adcetris) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Codes
