ADCETRIS (brentuximab)

ADCETRIS (brentuximab)

OFFICE ADMINISTERED

Indication(s) for Prior Authorization:

• Hodgkin Lymphoma, refractory/relapsed
• Systemic anaplastic large cell lymphoma (sALCL), refractory

Patients must meet all the following criteria for the indication above:

Hodgkin Lymphoma, refractory/relapsed

• Diagnosis is relapsed or refractory Hodgkin Lymphoma AND

• Being used as monotherapy AND
• Either of the following
  • Failure or inadequate response to High Dose Therapy/Autologous Stem Cell Rescue (HDT/ASCR) OR
  • Failed at least two prior multi-agent chemotherapy regimens, if patient is not a candidate for HDT/ASCR

Systemic anaplastic large cell lymphoma (sALCL), refractory

• Diagnosis of refractory systemic anaplastic large cell lymphoma AND
• Being used as monotherapy AND
• Failure or inadequate response to at least one multi-agent chemotherapy regimen

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:

• Disease states not listed above
• Relapsed/refractory cutaneous ALCL

Dosing:

• Up to 1.8mg/kg IV infusion every 3 weeks*

*for patients >100 kg, dose should be calculated using a weight of 100kg