Subject: Specialty Quantity Limit lenalidomide-Revlimid P2388-H 2025

Drug

REVLIMID  (lenalidomide)

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

The standard limits may apply to the generic equivalent medications.

Medication	Standard Limit
Revlimid (lenalidomide) capsules 2.5mg	28 per 28 days
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

FDA-recommended Dosing

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.

Dose modifications may be needed for adverse reactions and renal impairment.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Revlimid [package insert]. Princeton, NJ: Celgene Corporation; March 2023.
2. Lenalidomide [package insert]. Bridgewater, NJ: Amneal Pharmaceuticals LLC; 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.

April 18, 2026