MedicaidPrior AuthHigh impact
Adcetris® (brentuximab vedotin) (New)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 1, 2026
Summary
Humana Medicaid Ohio has implemented a new prior authorization policy for Adcetris (brentuximab vedotin) effective July 1, 2026. The policy covers seven distinct indications for Hodgkin lymphoma, large B-cell lymphoma, anaplastic large cell lymphoma, and mycosis fungoides, each with specific clinical criteria and approval durations of 6 months. Billing teams must implement prior authorization requirements before this effective date and ensure all seven indication pathways are correctly mapped in authorization systems.
Action Required
By June 15, 2026: Billing and prior authorization teams must complete the following: (1) Update billing system and authorization workflow to require prior authorization for HCPCS code J9311 (Adcetris intravenous solution) for all Medicaid Ohio members effective July 1, 2026; (2) Map all seven indication-specific approval criteria into the prior authorization system: Hodgkin lymphoma (previously untreated), Hodgkin lymphoma (relapsed/refractory), Hodgkin lymphoma (consolidation post-HSCT), large B-cell lymphoma (relapsed/refractory), sALCL or CD30+ PTCL (previously untreated), sALCL (relapsed/refractory), and pcALCL or CD30+ mycosis fungoides; (3) Configure system to apply appropriate exclusion rules (disease progression on Adcetris blocks approval for five indications); (4) Train oncology providers and clinical staff on documentation requirements for each indication pathway, particularly CD30-positivity documentation for T-cell lymphomas and prior therapy line requirements for LBCL; (5) Update encounter templates to capture required clinical data per indication (e.g., HSCT eligibility status for LBCL, prior therapy documentation); (6) Establish internal workflow to alert providers when prior authorization is pending and approval duration limits approach (6-month initial and renewal cycles). Failure to implement prior authorization by July 1, 2026 will result in claim denials for all Adcetris administration for Medicaid Ohio members.