Subject: Specialty Quantity Limit lenalidomide-Revlimid 2388-H P2022

Drug

REVLIMID  (lenalidomide)

lenalidomide

Policy:

      I.  PROGRAM DESCRIPTION

          The standard limit is designed to allow a quantity sufficient for
          the most common uses of the medication. The recommended
          dosing parameters for all FDA-approved indications fall within
          the standard limits. Coverage of an additional quantity may be
          reviewed on a case-by-case basis upon request.

 
    II.  COVERED QUANTITIES

Medication	Standard Limit*	FDA-recommended dosing
Revlimid   (lenalidomide)   capsules 2.5mg	28 per 28 days	Multiple myeloma combination therapy: 25 mg   once daily orally on days 1-21 of repeated   28-day cycles.   Multiple myeloma maintenance therapy   following autologous hematopoietic stem cell   transplantation: 10 mg once daily orally on   days 1-28 of repeated 28-day cycles. After 3   cycles of maintenance therapy, the dose can   be increased to 15 mg once daily if tolerated.   Myelodysplastic syndromes: 10 mg once daily   orally.   Mantle cell lymphoma: 25 mg once daily orally   on days 1-21 of repeated 28-day cycles.   Follicular lymphoma and marginal zone   lymphoma: 20 mg once daily orally on   days 1-21 of repeated 28-day cycles for   up to 12 cycles.
Revlimid   (lenalidomide)   capsules 5mg	28 per 28 days
Revlimid   (lenalidomide)   capsules 10mg	28 per 28 days
Revlimid   (lenalidomide)   capsules 15mg	28 per 28 days
Revlimid   (lenalidomide)   capsules 20mg	21 per 28 days
Revlimid   (lenalidomide)   capsules 25mg	21 per 28 days

  *The standard limits may apply to the generic equivalent medications.

Place of Service:

Outpatient

The above policy is based on the following references:

 

1. Revlimid [package insert]. Summit, NJ: Celgene Corporation; May 2022.
2. Lenalidomide [package insert]. Parsippany, NJ: Teva Pharmaceuticals; May 2022.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

April 15, 2023