By Counterforce Health Team in Revlimid (lenalidomide) —

Get Revlimid (lenalidomide) Covered by UnitedHealthcare in Georgia: Complete Forms, Appeals & Approval Guide

Answer Box: Fastest Path to Approval

To get Revlimid (lenalidomide) covered by UnitedHealthcare in Georgia: First, verify your prescriber and pharmacy are REMS-certified through Bristol Myers Squibb's program. Second, submit the UnitedHealthcare Revlimid PA form via the Provider Portal with complete diagnosis, prior therapy documentation, and REMS authorization numbers. Third, if denied, file an internal appeal within 180 days and prepare for Georgia's external review process if needed. Most approvals come within 72 hours when REMS requirements are met and clinical criteria are properly documented.

Table of Contents

  1. Start Here: Verify Your Plan & Requirements
  2. Required Forms & Documentation
  3. Submission Portals & Online Access
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Setup
  6. Support Lines & Case Management
  7. Appeals Process in Georgia
  8. State Resources & Consumer Help
  9. Common Denial Reasons & Solutions
  10. Costs & Patient Assistance
  11. FAQ

Start Here: Verify Your Plan & Requirements

Before submitting any paperwork, confirm these essential details:

Check Your Coverage Status:

  • Call the member services number on your UnitedHealthcare card
  • Verify Revlimid is on your plan's formulary (drug list)
  • Confirm your current deductible and copay tier
  • Ask about any quantity limits or step therapy requirements

REMS Certification Requirements: Revlimid requires strict Risk Evaluation and Mitigation Strategy (REMS) compliance due to serious birth defect risks. Both your prescriber and pharmacy must be certified through Bristol Myers Squibb's REMS program.

Critical: No prescription can be filled without valid REMS authorization numbers. This is the #1 reason for denials.

Required Forms & Documentation

Primary Prior Authorization Form

UnitedHealthcare Revlimid PA Notification Form - Download the current version from the UnitedHealthcare Provider Portal.

Required Clinical Information:

  • Primary diagnosis with ICD-10 code
  • Indication-specific details:
    • Multiple Myeloma: Combination with dexamethasone or maintenance post-transplant
    • MDS: Confirmation of del(5q) abnormality
    • Mantle Cell Lymphoma: Documentation of relapse after two prior therapies including bortezomib
    • Follicular/Marginal Zone Lymphoma: Pairing with rituximab for previously treated patients
  • Complete prior treatment history with dates and outcomes
  • Laboratory results and staging information
  • Prescriber specialty (oncologist/hematologist required)

Supporting Documentation

Medical Necessity Letter Checklist:

  • Patient's specific cancer diagnosis and stage
  • Prior therapies attempted, including dates and reasons for discontinuation
  • Clinical rationale citing NCCN Guidelines or FDA labeling
  • Contraindications to alternative treatments
  • Dosing schedule and monitoring plan
  • Treatment goals and expected duration
Clinician Tip: Include peer-reviewed studies supporting off-label use when applicable, and reference specific NCCN guideline pages for your indication.

Submission Portals & Online Access

UnitedHealthcare Provider Portal

Primary Submission Method: UHCProvider.com

Setup Requirements:

  • One Healthcare ID account with multi-factor authentication
  • Choose from passkey, authenticator app, or phone verification
  • Upload documents directly through the portal interface

Portal Benefits:

  • Real-time status tracking
  • Automated approvals possible for complete submissions
  • Standard processing within 72 hours for commercial plans
  • Immediate confirmation numbers for submitted requests

Alternative Submission

If portal access isn't available, fax completed forms to the number listed on the PA form (verify current fax number when downloading the form).

Fax Numbers & Mailing Addresses

Prior Authorization Contacts

Specialty Guidance Program:

General UnitedHealthcare:

  • Member Services: Number on your insurance card
  • Provider Services: 1-800-842-3211

Appeals Contacts

Internal Appeals:

  • Submit through UnitedHealthcare Provider Portal
  • Phone: 1-866-633-2446
  • Standard deadline: 180 days from denial date

Part D Prescription Appeals:

  • Phone: 1-877-960-8235
  • Mail: UnitedHealthcare Part D Appeal and Grievance Department, P.O. Box 30883
Note: Always verify current contact information when calling, as numbers may change. Keep confirmation numbers from all submissions.

Specialty Pharmacy Setup

UnitedHealthcare requires Revlimid to be dispensed through OptumRx or another approved specialty pharmacy.

Setup Process:

  1. Physician enrollment: Your doctor must establish an account with the designated specialty pharmacy
  2. Prescription transfer: Provide REMS authorization number and PA approval confirmation
  3. Patient onboarding: Complete pharmacy intake forms and insurance verification
  4. Delivery coordination: Schedule shipments and confirm receipt protocols

Required Information:

  • Valid REMS confirmation number for each prescription
  • UnitedHealthcare PA approval reference number
  • Complete shipping address and delivery preferences
  • Emergency contact information

Support Lines & Case Management

Member Support

UnitedHealthcare Customer Service:

  • General: Number on insurance card
  • Pharmacy Benefits: 1-877-842-3210
  • Medicare Advantage (Georgia): 1-877-246-4190

What to Ask:

  • Current status of your PA request
  • Specific denial reasons and required documentation
  • Appeal deadlines and submission methods
  • Formulary tier and coverage details

Provider Support

Clinical Support:

  • Specialty Guidance Program: 1-888-397-8129
  • Peer-to-peer reviews available for complex cases
  • Medical director consultations for denied requests

Counterforce Health helps patients, clinicians, and pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals using the right medical evidence and payer-specific workflows, saving time while improving approval rates.

Appeals Process in Georgia

Internal Appeals (Required First Step)

Timeline: 180 days from denial date Method: UnitedHealthcare Provider Portal or written request Documentation: Original denial letter, additional clinical evidence, prescriber attestation

Georgia External Review Process

If your internal appeal is denied, Georgia law provides an independent external review through the Georgia Department of Insurance.

Key Requirements:

  • Submit within 60 days of final internal denial
  • Request form by emailing [email protected]
  • Process is free for consumers
  • Decision typically within 30 business days (72 hours for urgent cases)

Required Documents:

  • Insurance card copy
  • All denial letters and internal appeal responses
  • Supporting documentation from healthcare providers
  • Insurance policy information
  • Complete treatment history
Georgia-Specific: You can request expedited external review concurrent with internal appeals if delay poses serious health risks.

State Resources & Consumer Help

Georgia Department of Insurance

Consumer Services Hotline: 1-800-656-2298 Online: File Insurance Complaint

Services Provided:

  • External review application assistance
  • Insurance complaint investigation
  • Consumer education and advocacy
  • Informal mediation with insurers

Additional Georgia Resources

Georgians for a Healthy Future: Nonprofit providing consumer assistance with appeals and coverage issues Georgia Legal Services: Free legal aid for Medicaid/PeachCare appeals

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
REMS non-compliance Verify prescriber/pharmacy certification REMS authorization numbers
Missing diagnosis details Submit complete pathology report ICD-10 codes, staging information
Step therapy required Document prior treatment failures Treatment history with dates/outcomes
Non-formulary status Request medical exception Clinical necessity letter
Quantity limits exceeded Justify dosing schedule Weight-based calculations, protocol citations

Costs & Patient Assistance

Manufacturer Support

Bristol Myers Squibb Access Support:

  • Copay assistance programs
  • Prior authorization support templates
  • Financial hardship programs
  • Patient navigation services

Additional Resources

Foundation Assistance:

  • Leukemia & Lymphoma Society
  • CancerCare Co-Payment Assistance Foundation
  • Patient Access Network Foundation

Eligibility: Most programs require insurance coverage but help with out-of-pocket costs.

From our advocates: "We've seen patients save thousands by applying for manufacturer copay cards before their first fill. The key is starting the application process while your PA is being reviewed, not after approval."

FAQ

How long does UnitedHealthcare PA take in Georgia? Standard processing is 72 hours for commercial plans. Expedited reviews available for urgent medical situations.

What if Revlimid is non-formulary on my plan? Request a formulary exception with clinical documentation showing medical necessity and lack of suitable alternatives.

Can I request an expedited appeal in Georgia? Yes, for urgent medical situations. Both UnitedHealthcare and Georgia's external review process offer expedited timelines.

Does step therapy apply if I've tried treatments outside Georgia? Yes, document all prior therapies regardless of where treatment occurred. Include complete medical records and treatment summaries.

What happens if my REMS certification expires? Treatment must stop immediately. Your prescriber and pharmacy must recertify before any new prescriptions can be filled.

How do I transfer from another specialty pharmacy? Contact your new OptumRx pharmacy with your current prescription information and REMS authorization numbers. They'll coordinate the transfer.

Counterforce Health's platform helps streamline this complex process by analyzing your specific denial and creating targeted appeals using evidence-backed medical necessity arguments. Visit counterforcehealth.org to learn how we can help turn your denial into an approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific insurance plan and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For official Georgia insurance regulations and consumer rights, visit the Georgia Department of Insurance website.

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