lenalidomide — CareFirst (Caremark)

Initial criteria

• Authorization of 12 months may be granted for treatment of multiple myeloma.
• Authorization of 12 months may be granted for treatment of T-cell lymphoma, as a single agent, with any of the following subtypes: Peripheral T-Cell Lymphomas not otherwise specified as initial palliative therapy or subsequent therapy; Angioimmunoblastic T-cell lymphoma as initial palliative therapy or subsequent therapy; Enteropathy-associated T-cell lymphoma as initial palliative therapy or subsequent therapy; Monomorphic epitheliotropic intestinal T-cell lymphoma as initial palliative therapy or subsequent therapy; Nodal peripheral T-cell lymphoma with TFH phenotype as initial palliative therapy or subsequent therapy; Follicular T-cell lymphoma as initial palliative therapy or subsequent therapy; Adult T-cell leukemia/lymphoma as subsequent therapy; Hepatosplenic T-cell lymphoma as subsequent therapy.
• Authorization of 12 months may be granted for treatment of primary CNS lymphoma as a single agent or in combination with rituximab after prior therapy with Bruton Tyrosine Kinase inhibitor- and venetoclax-based regimens.
• Authorization of 12 months may be granted for treatment of CLL/SLL as a single agent or in combination with rituximab.
• Authorization of 12 months may be granted for treatment of B-cell lymphoma with any of the following subtypes: HIV-related B-Cell lymphomas, including non-germinal center diffuse large B-cell lymphoma, HIV-related diffuse large B-cell lymphoma, primary effusion lymphoma, HHV8+ diffuse large B-cell lymphoma, and HIV-related plasmablastic lymphoma, as subsequent therapy; Monomorphic post-transplant lymphoproliferative disorder as subsequent therapy; Diffuse large B-cell lymphoma as subsequent therapy; Follicular lymphoma; Marginal zone lymphoma with subtypes extranodal (nongastric/gastric MALT), splenic, or nodal, as subsequent therapy; High-grade B-cell lymphomas as subsequent therapy; Histologic transformation of indolent lymphomas to diffuse large B-cell lymphoma as subsequent therapy; Mantle cell lymphoma.
• Authorization of 12 months may be granted for treatment of multicentric Castleman disease as subsequent therapy.
• Authorization of 12 months may be granted for treatment of lower risk myelodysplastic syndrome (IPSS-R very low, low, intermediate; IPSS low/intermediate-1; WPSS very low, low, intermediate) for those with symptomatic anemia.
• Authorization of 12 months may be granted for treatment of systemic light chain amyloidosis.
• Authorization of 12 months may be granted for treatment of classic Hodgkin lymphoma that is refractory to at least 3 prior lines of therapy, as a single agent.
• Authorization of 12 months may be granted for treatment of POEMS syndrome when either of the following criteria are met: used in combination with dexamethasone; or used in combination with dexamethasone and daratumumab as induction therapy for transplant eligible patients.
• Authorization of 12 months may be granted for treatment of myelodysplastic/myeloproliferative neoplasms, as a single agent or in combination with a hypomethylating agent.
• Authorization of 12 months may be granted for treatment of Kaposi sarcoma as subsequent therapy.
• Authorization of 12 months may be granted for treatment of asymptomatic high-risk smoldering myeloma.
• Authorization of 12 months may be granted for treatment of histiocytic neoplasms, including Langerhans cell histiocytosis and Rosai-Dorfman disease, as a single agent.

Reauthorization criteria

• Authorization of 12 months may be granted for continued treatment when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Approval duration

12 months