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The Policy VaultThe Policy Vault

Revlimid — CareFirst (Caremark)

T-cell Lymphomas (Peripheral T-Cell Lymphomas not otherwise specified, Angioimmunoblastic T-cell lymphoma, Enteropathy-associated T-cell lymphoma, Monomorphic epitheliotropic intestinal T-cell lymphoma, Nodal peripheral T-cell lymphoma with TFH phenotype, Follicular T-cell lymphoma, Adult T-cell leukemia/lymphoma, Hepatosplenic T-cell lymphoma)

Initial criteria

  • Treatment of T-cell lymphoma, as a single agent, for the listed subtypes as initial palliative therapy or subsequent therapy (subsequent therapy only for Adult T-cell leukemia/lymphoma and Hepatosplenic T-cell lymphoma).

Reauthorization criteria

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

Approval duration

12 months