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The Policy VaultThe Policy Vault

Revlimid — CareFirst (Caremark)

B-Cell Lymphomas (HIV-related B-cell lymphomas, Monomorphic post-transplant lymphoproliferative disorder, Diffuse large B-cell lymphoma, Follicular lymphoma, Marginal zone lymphoma, Multicentric Castleman disease, High-grade B-cell lymphomas, Histologic transformation of indolent lymphomas, Mantle cell lymphoma)

Initial criteria

  • Authorization may be granted for treatment of B-cell lymphoma with listed subtypes as subsequent therapy, except follicular lymphoma and mantle cell lymphoma which are not restricted to subsequent therapy.

Reauthorization criteria

  • No evidence of unacceptable toxicity or disease progression while on the current regimen.

Approval duration

12 months