UnitedHealthcare
Revlimid (lenalidomide)
Drugs for Cancer : Drugs for Cancer
  • Quantity Limit: limit maximum 1 EA PER 1 day(s)
  • Prior Authorization: Chronic Lymphocytic Leukemia, Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Marginal Zone Lymphoma, Multiple Myeloma, Non Hodgkin Lymphoma (NHL):
    Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

    Mantle Cell Lymphoma:
    Documented Diagnosis: Yes
    Age Requirement: > 19
    Duration: 12 Month(s)
    Reauthorization Required: Yes

    Myelodysplastic Syndrome:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Orally administered anticancer medication.
  • Step Therapy: Chronic Lymphocytic Leukemia:
    ST Single Generic

    Myelodysplastic Syndrome:
    ST Single Brand

  • Chronic Lymphocytic Leukemia:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Drug Policy Based On: NCCN Guidelines
    Diagnosis Types: 1 of All NCCN indications with evidence level of 2A or higher;CLL for relapsed/refractory disease;patients with CLL who have received at least one prior therapy;Small Lymphocytic Lymphoma

    Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Marginal Zone Lymphoma, Non Hodgkin Lymphoma (NHL):
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Mantle Cell Lymphoma:
    Age Requirement: > 19
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Multiple Myeloma:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Drug Policy Based On: NCCN Guidelines
    ECOG Score Requirement in Policy: N/A
    ECOG status <=2: No
    Diagnosis Types: 1 of All NCCN indications with evidence level of 2A or higher;As maintenance or salvage therapy for the treatment of multiple myeloma;Multiple Myeloma;Multiple Myeloma in combination with dexamethasone
    Concomitant Therapy Requirement: in combination with dexamethasone

    Myelodysplastic Syndrome:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

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