Thalomid (thalidomide) — Highmark

Initial criteria

• The member has a diagnosis of multiple myeloma (ICD-10 C90.0) OR
• The member has a diagnosis of cutaneous manifestations of moderate to severe ENL (ICD-10 L52) OR
• The member is being prescribed Thalomid for ENL prophylaxis

Reauthorization criteria

• 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

Approval duration

12 months