Coverage Policies

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INDEX:



Effective Date: 01/01/2012	Title: Adcetris (Brentuximab)
Revision Date: 10/01/2019	Document: BI334:00
CPT Code(s): 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 pre-authorization. 2) Adcetris is considered a specialty medication. 3) Adcetris is used to treat several different types of lymphoma and mycosis fungoides/Sezary syndrome.
Medical Statement
Adcetris is considered medically necessary for members > 18 years old who meet the following criteria: a) 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 b) Non-Hodgkin T-Cell Lymphomas i) Diagnosis of one of the following: (1) Peripheral T-cell lymphoma (PTCL); (2) Breast implant-associated anaplastic large cell lymphoma (stage II-IV); (3) Adult T-cell leukemia/lymphoma (a) Failure of at least one prior multi-agent chemotherapy regimen; OR (b) Subsequent therapy after high dose therapy/autologous stem cell rescue (HDT/ASCR) c) Primary Cutaneous CD30+ T-cell Lymphomproliferative Disorder i) Diagnosis of one of the following: (1) CD 30-positive pcALCL (2) Cutaneous ALCL with regional nodes (excludes sALCL) (3) Lymphomatoid papulosis (LyP) withextensivelesions if relapsed/refractory to retreatment with primary treatment or retreatment with alternative regimen not used for primary treatment d) Mycosis Fungoides/Sezary Syndrome i) Diagnosis of one of CD 30-expressing mycosis fungoides or Sezary syndrome Codes Used In This BI: J9042 Injection, brentuximab vedotin, 1mg
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. 3) NCCN Guidelines. Accessed online 5/6/2019.
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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