Revlimid (lenalidomide) — Highmark

mantle cell lymphoma

Initial criteria

For multiple myeloma: age ≥ 18 years AND diagnosis of multiple myeloma (ICD-10 C90.0) AND use in combination with dexamethasone OR after autologous hematopoietic stem cell transplantation
For mantle cell lymphoma: age ≥ 18 years AND diagnosis of mantle cell lymphoma (ICD-10 C83.1) AND disease has relapsed or progressed after two prior therapies, one of which included bortezomib
For myelodysplastic syndromes with 5q deletion: age ≥ 18 years AND diagnosis of MDS with 5q deletion (ICD-10 D46) AND transfusion-dependent anemia OR hemoglobin < 10 g/dL
For follicular lymphoma: age ≥ 18 years AND diagnosis of follicular lymphoma (ICD-10 C82.9) AND use in combination with a rituximab product
For marginal zone lymphoma: age ≥ 18 years AND diagnosis of marginal zone lymphoma (ICD-10 C88) AND use in combination with a rituximab product

The prescriber attests that the member is tolerating therapy AND
The member has experienced a therapeutic response defined as disease improvement OR delayed disease progression

12 months