By Counterforce Health Team in Revlimid (lenalidomide) —

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

Answer Box: Quick Path to Approval

To get Revlimid (lenalidomide) covered by UnitedHealthcare in Michigan: 1) Verify your plan requires prior authorization through OptumRx, 2) Submit the PA form with diagnosis documentation (multiple myeloma or MDS with 5q deletion qualify automatically), and 3) Ensure REMS program compliance before dispensing. If denied, you have 180 days for internal appeals, then 127 days for Michigan DIFS external review. Start with the UnitedHealthcare Provider Portal today.

Table of Contents

  1. Start Here: Verify Your Plan & Policy
  2. Required Forms & Documentation
  3. Submission Portals & Online Tools
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Requirements
  6. Support Lines & Who to Call
  7. Michigan Appeals Process
  8. Common Denial Reasons & Solutions
  9. When to Escalate
  10. FAQ

Start Here: Verify Your Plan & Policy

Before diving into forms and appeals, confirm your UnitedHealthcare plan's specific requirements for Revlimid (lenalidomide). All UnitedHealthcare plans use OptumRx as their pharmacy benefits manager, which means your prior authorization will be processed through OptumRx's system.

First steps:

  • Check your member ID card for "OptumRx" or pharmacy benefits information
  • Log into your UnitedHealthcare member portal to view your prescription drug coverage
  • Verify whether you have commercial, Medicare Advantage, or Medicaid coverage, as requirements differ slightly
Note: Revlimid requires prior authorization for all UnitedHealthcare plans and strict REMS program compliance due to serious safety risks.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans OptumRx PA form UHC Provider Portal
REMS Compliance Mandatory safety program FDA REMS info FDA
Approved Indications Multiple myeloma, MDS PA notification document UHC Policy
Reauthorization Every 12 months Same PA form OptumRx
Appeals Deadline 180 days internal, 127 days external Michigan DIFS MI DIFS

Required Forms & Documentation

Primary Prior Authorization Form

UnitedHealthcare uses a specific Revlimid PA notification form effective August 2025. Your prescriber must complete this form with:

Required clinical information:

  • Primary diagnosis with ICD-10 codes
  • For multiple myeloma: Documentation of diagnosis
  • For MDS: Documentation of symptomatic anemia and genetic testing results (5q deletion status)
  • NCCN compendium category if applicable (Category 1, 2A, or 2B automatically qualify)

Supporting documents to attach:

  • Recent lab results showing blood counts
  • Pathology reports confirming diagnosis
  • Prior treatment history and outcomes
  • Clinical notes supporting medical necessity

REMS Program Documentation

Before any approval, patients and prescribers must complete Revlimid REMS requirements:

  • Prescriber enrollment and certification
  • Patient-physician agreement form
  • Pregnancy testing documentation (women of childbearing potential)
  • Contraception counseling records

Submission Portals & Online Tools

UnitedHealthcare Provider Portal

The fastest submission method is through the UnitedHealthcare Provider Portal using your One Healthcare ID. As of March 2025, you'll need multifactor authentication:

  • Passkey (biometrics, PIN, Face ID)
  • Authenticator app plus phone number
  • Password plus phone number

Portal features:

  • Prior Authorization and Notification tool
  • Direct document upload capability
  • Real-time status tracking
  • Automated approval for qualifying cases (under 30 seconds when criteria are met)
Tip: OptumRx offers EMR integration for automated prior authorization through their PreCheck system, dramatically reducing approval times.

Member Portal Access

Patients can track their PA status through the UnitedHealthcare member portal and upload additional documentation if requested.

Fax Numbers & Mailing Addresses

Specialty Pharmacy & Prior Authorization

  • Prior Authorization Fax: 866-940-7328
  • Prior Authorization Phone: 800-310-6826
  • OptumRx General Fax: 800-527-0531

Appeals & Grievances

Mailing Address: UnitedHealthcare Member Grievance & Appeals
P.O. Box 31364
Salt Lake City, UT 84131-0364

Urgent Appeals Fax: 801-994-1261

Cover Sheet Tips

When faxing documents:

  • Include patient name and member ID on every page
  • Reference "Revlimid Prior Authorization" in the subject line
  • Number pages clearly (Page X of Y)
  • Include your callback number for questions

Specialty Pharmacy Requirements

Revlimid must be dispensed through certified specialty pharmacies due to REMS requirements. UnitedHealthcare works with Optum Specialty Pharmacy and other certified partners.

Transfer Process

  1. Your prescriber submits the approved PA to a REMS-certified pharmacy
  2. Pharmacy verifies REMS compliance before dispensing
  3. Patient completes required safety monitoring
  4. Medication is shipped with tracking and signature requirements

Optum Specialty Pharmacy Contact: 800-310-6826

Support Lines & Who to Call

For Patients

  • Pharmacy General Support: 800-711-4555
  • Member Services: Use number on your ID card
  • OptumRx Mail Order: 855-473-8889

For Providers

  • Provider Services: 800-842-3211
  • Prior Authorization Help: 800-310-6826
  • One Healthcare ID Support: 855-819-5909

Michigan-Specific Support

  • Michigan Medicaid Pharmacy Help: 1-800-903-5253
  • Michigan DIFS Consumer Assistance: 877-999-6442

What to ask when calling:

  • "What specific documentation is needed for Revlimid approval?"
  • "Can you expedite this PA due to treatment urgency?"
  • "What's the status of PA request [reference number]?"

Michigan Appeals Process

If UnitedHealthcare denies your Revlimid coverage, Michigan law provides strong appeal rights under the Patient's Right to Independent Review Act.

Internal Appeals (First Step)

  • Deadline: 180 days from denial notice
  • How to file: UnitedHealthcare member portal, mail, or fax
  • Timeline: Standard review within 30 days, expedited within 72 hours

External Review (Final Step)

If UnitedHealthcare upholds the denial:

  • Deadline: 127 days from final internal denial
  • How to file: Michigan DIFS External Review form
  • Timeline: 60 days maximum, often faster
  • Expedited option: 72 hours with physician letter stating urgency

Required documents for external review:

  • Copy of UnitedHealthcare's final denial
  • Your reasons for appealing
  • All supporting medical documentation
  • Completed DIFS external review form
Important: The 127-day deadline is strict. Missing it means losing your right to external review.

At Counterforce Health, we help patients and providers navigate complex insurance appeals by analyzing denial letters and crafting evidence-backed responses that align with each payer's specific requirements. Our platform streamlines the appeals process by identifying the exact denial reasons and generating targeted rebuttals with appropriate clinical citations.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Missing REMS compliance Complete all REMS requirements REMS enrollment confirmation
Insufficient diagnosis documentation Submit detailed pathology reports ICD-10 codes, biopsy results
Off-label use without compendium support Provide NCCN or other recognized guidelines Peer-reviewed literature
Inadequate prior therapy documentation Detail previous treatments and failures Treatment history, outcomes
Quantity limits exceeded Justify dosing with clinical rationale Physician letter, dosing guidelines

When to Escalate

Contact Michigan regulators if you experience:

  • Repeated inappropriate denials
  • Failure to meet appeal deadlines
  • Lack of response to urgent requests
  • Violations of state insurance laws

Michigan Department of Insurance and Financial Services (DIFS)

For Medicaid issues, also contact: Michigan Department of Health and Human Services

  • Medicaid complaints and appeals process
  • State-specific coverage requirements

FAQ

How long does UnitedHealthcare prior authorization take for Revlimid in Michigan? Standard PA decisions are made within 72 hours for commercial plans. Automated approvals through OptumRx PreCheck can happen in under 30 seconds when all criteria are clearly met.

What if Revlimid isn't on my formulary? Even non-formulary drugs can be covered with proper medical necessity documentation. Focus on diagnosis codes, failed prior therapies, and NCCN guideline support.

Can I request an expedited appeal in Michigan? Yes, Michigan offers expedited external appeals decided within 72 hours when a physician certifies that delays would harm the patient's health.

Does step therapy apply if I've already failed treatments outside Michigan? Document all prior treatments with dates, dosages, and outcomes. UnitedHealthcare typically accepts out-of-state treatment history with proper documentation.

What happens if I miss the 127-day appeal deadline? You lose the right to external review through Michigan DIFS. However, you may still have other options through federal programs or legal channels.

How much does Revlimid cost without insurance? List prices exceed $15,000 per 21-28 day cycle. Manufacturer assistance programs and patient foundations may help reduce costs.

Do I need a specialty pharmacy for Revlimid? Yes, REMS requirements mandate dispensing through certified specialty pharmacies only. Optum Specialty Pharmacy is UnitedHealthcare's preferred partner.

Can my doctor help with the appeal process? Absolutely. Physicians can file appeals on your behalf with written authorization and often provide crucial clinical documentation that strengthens your case.

When facing complex insurance denials, Counterforce Health specializes in turning rejections into successful appeals by analyzing each payer's specific requirements and generating targeted, evidence-based responses that speak directly to plan policies and medical necessity criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan directly for specific coverage questions. For personalized assistance with insurance appeals and prior authorization challenges, consider consulting with healthcare coverage specialists.

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