MedicaidPrior AuthMedium impact
Adcetris® (brentuximab vedotin) (New)
Humana·IN · Oncology, Hematology·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 1, 2026
Summary
Humana Medicaid Indiana has implemented a new prior authorization policy for Adcetris (brentuximab vedotin) effective July 1, 2026. This policy requires prior auth approval for seven distinct lymphoma indications with specific clinical criteria, approval durations of 6 months initially and at renewal, and explicit exclusions for patients experiencing disease progression on the drug.
Action Required
By June 1, 2026: Billing team and oncology providers must implement prior authorization workflow for Adcetris (J9310) for all Indiana Medicaid members. Specific actions: (1) Update billing software to flag J9310 claims for Indiana Medicaid members requiring prior auth submission before dispensing; (2) Create or update prior auth request forms to capture required clinical criteria specific to each indication (e.g., disease status, prior therapy lines, combination regimen details, CD30 positivity documentation); (3) Train providers to document in EMR: diagnosis confirmation, treatment line/prior therapy history, whether disease is previously untreated/relapsed/refractory, specific combination regimen or monotherapy use, and any prior Adcetris exposure/response; (4) Establish internal tracking for initial 6-month approvals and renewal submissions 30 days before expiration; (5) Flag claims for automatic denial if member has documented disease progression while on Adcetris. Front desk staff must verify member plan type before scheduling infusions. Failure to obtain prior authorization will result in claim denials and delayed treatment.