Subject: Specialty Quantity Limit Lenvima 1698-H P2025

Drug

LENVIMA  (lenvatinib)

Policy:

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.

Covered Quantities

Lenvima is available in 4 mg and 10 mg capsules. These are packed in cards in various combinations to obtain the desired dose.

Medication	Standard Limit
Lenvima (lenvatinib) 4 mg 30-day dose carton	1 carton (30 capsules total) per 30 days
Lenvima (lenvatinib) 8 mg 30-day dose carton	1 carton (60 capsules total) per 30 days
Lenvima (lenvatinib) 10 mg 30-day dose carton	1 carton (30 capsules total) per 30 days
Lenvima (lenvatinib) 12 mg 30-day dose carton	1 carton (90 capsules total) per 30 days
Lenvima (lenvatinib) 14 mg 30-day dose carton	1 carton (60 capsules total) per 30 days
Lenvima (lenvatinib) 18 mg 30-day dose carton	1 carton (90 capsules total) per 30 days
Lenvima (lenvatinib) 20 mg 30-day dose carton	1 carton (60 capsules total) per 30 days
Lenvima (lenvatinib) 24 mg 30-day dose carton	1 carton (90 capsules total) per 30 days

FDA-Recommended Dosing

Differentiated thyroid cancer

24 mg once daily

Renal cell carcinoma

18 mg once daily when used in combination with everolimus; 20 mg once daily when used in combination with pembrolizumab

Hepatocellular carcinoma

8 mg once daily for patients less than 60 kg; 12 mg once daily for patients greater than or equal to 60 kg

Endometrial carcinoma

20 mg once daily

Dose reductions

Dose reductions may be required after adverse events or in patients with severe renal or hepatic impairment.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Lenvima [package insert]. Nutley, NJ: Eisai Inc.; January 2025.

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.

January 01, 2026