Relapsed or refractory Hodgkin lymphoma - brentuximab (autologous stem cell transplant (ASCT) naïve) initial PBS authority form (PB205)

Use this form to apply for initial PBS subsidised treatment with brentuximab vedotin for relapsed or refractory Hodgkin lymphoma and who is ASCT naïve.

This PDF is fillable. Download this form and complete it on your device, or print it and complete it by hand.

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Page last updated: 13 February 2019

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This information was printed 21 July 2019 from https://www.humanservices.gov.au/organisations/health-professionals/forms/pb205. It may not include all of the relevant information on this topic. Please consider any relevant site notices at https://www.humanservices.gov.au/individuals/site-notices when using this material.