Brentuximab vedotin (Adcetris®) 


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


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

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


Last review date: December 1, 2014

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