MedicaidPrior AuthMedium impact
Adcetris® (brentuximab vedotin) (New)
Humana·LA · Oncology, Hematology·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 1, 2026
Summary
Humana Medicaid Louisiana has implemented a new pharmacy prior authorization policy for Adcetris® (brentuximab vedotin) effective July 1, 2026. This policy establishes specific clinical criteria for coverage across seven indications including Hodgkin lymphoma, large B-cell lymphoma, and T-cell lymphomas. All Adcetris prescriptions require prior authorization with approval durations of 6 months or as clinically determined.
Action Required
By June 15, 2026: Billing and pharmacy teams must configure prior authorization workflows in practice management and pharmacy systems for Adcetris (J9042). Update encounter forms and prescription templates to prompt providers to document the specific indication (Hodgkin lymphoma, LBCL, sALCL/PTCL, or pcALCL/MF) and treatment line status (previously untreated, relapsed, or refractory). Providers and clinical staff must ensure all submitted prior auth requests include: (1) confirmed diagnosis with CD30 positivity when required, (2) prior therapy history and lines of treatment, (3) confirmation of eligibility/ineligibility for HSCT or CAR-T when applicable, (4) combination therapy regimen details. Before July 1, 2026: Train billing staff on the seven distinct approval pathways and their clinical criteria. Create a reference checklist for prior auth submissions. Communicate with prescribing physicians regarding the new approval process. Failure to obtain prior authorization will result in claim denials; claims submitted without meeting the specified clinical criteria for the indicated condition will not be covered.