Coverage Policies

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INDEX:



Effective Date: 01/01/2012	Title: Adcetris (Brentuximab)
Revision Date: 10/01/2015	Document: BI334:00
CPT Code(s): C9287, J9042
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. 1) Adcetris (Brentuximab) requires prior authorization. 2) Adcetris is considered a specialty medication. 3) Adcetris is used to treat Hodgkin’s disease and systemic anaplastic large cell lymphoma (sALCL).
Medical Statement
Adcetris is considered medically necessary for members who meet the following criteria: 1) Diagnosis of Hodgkin’s lymphoma (C81.00-C81.99)who have failed autologous stem cell transplant (ASCT) or, if not a candidate for ASCT, have failed at least two prior multi-agent chemotherapy regimens; OR 2) Diagnosis of systemic anaplastic large cell lymphoma (sALCL) (C84.60-C84.79) after failure of at least one multi-agent chemotherapy regimen. Codes Used In This BI: C9287 Injection, brentuximab vedotin, 1 mg (For billing prior to 1/1/12 use J9999 or C9399) J9042 Injection, brentuximab vedotin, 1mg (Effective 1/1/2013)
Limits
Adcetris is limited to a maximum of 16 cycles.
Reference
1) Adcetris Product Information. Seattle Genetics. August 2011. 2) Clinical Pharmacology Online. “brentuximab”, retrieved November 2011.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

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