CurrentNeighborhood Health Plan of Rhode IslandPolicy 1865-A
Lenvima Sgm 1865 A P2024_R
Defines prior authorization coverage criteria, indications (FDA and compendial), documentation requirements, authorization durations, and continuation criteria for lenvatinib across multiple oncologic indications.
Policy Summary
PayerNeighborhood Health Plan of Rhode Island
PolicyLenvima Sgm 1865 A P2024_R
Policy CodePolicy 1865-A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionSubmit prior authorization request with supporting documentation including laboratory report confirming mismatch repair (MMR) tumor status where applicable; authorization typically granted for 12 months when criteria are met.
SourceLink
POLICY UPDATE CHANGES
No material clinical/coverage changes
5FDA-approved indications listed
7Compendial uses listed
12Authorization duration (months)
Coverage Summary
Coverage stance: covered_with_criteria. This policy lists covered FDA-approved indications and compendial uses for lenvatinib and requires prior authorization. Documentation, including laboratory confirmation of MMR tumor status where applicable, must be submitted for review. Continuation of therapy may be authorized only when there is no evidence of unacceptable toxicity and no evidence of disease progression while on the current regimen.