By Counterforce Health Team in Revlimid (lenalidomide) —

Get Revlimid (lenalidomide) Covered by UnitedHealthcare in Washington: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Revlimid Covered by UnitedHealthcare in Washington

Revlimid (lenalidomide) requires prior authorization from UnitedHealthcare in Washington. The fastest path to approval: 1) Ensure your prescriber is REMS-certified and has all clinical documentation ready, 2) Submit the UnitedHealthcare Revlimid PA notification form through their provider portal with complete diagnosis and prior therapy records, 3) If denied, file an internal appeal within 180 days, then request external review through Washington's Independent Review Organization (IRO) process. Start by calling UnitedHealthcare at 866-889-8054 or your prescriber can submit through the provider portal today.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. REMS Requirements
  4. Common Denial Reasons
  5. Appeals Process in Washington
  6. Costs and Financial Assistance
  7. Specialty Pharmacy Requirements
  8. Renewal and Reauthorization
  9. Frequently Asked Questions
  10. When to Escalate

Coverage Basics

Is Revlimid Covered by UnitedHealthcare?

Yes, Revlimid is covered as a Specialty Tier 3 drug on UnitedHealthcare's formulary, but requires prior authorization for all indications. Coverage applies to FDA-approved uses including:

  • Multiple myeloma (newly diagnosed and relapsed/refractory)
  • Myelodysplastic syndromes with 5q deletion
  • Mantle cell lymphoma (maintenance after response)

Which UnitedHealthcare Plans Cover Revlimid?

All UnitedHealthcare plans in Washington that include prescription drug coverage will cover Revlimid with prior authorization. This includes:

  • Commercial employer plans
  • Individual marketplace plans
  • Medicare Advantage plans
  • Medicaid managed care plans

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify REMS Compliance (Prescriber): Ensure enrollment in the Lenalidomide REMS program with authorization number
  2. Gather Documentation (Clinic): Collect pathology reports, ICD-10 codes, prior therapy records, and current labs
  3. Complete PA Form (Prescriber): Submit UnitedHealthcare Revlimid PA notification form
  4. Submit Request: Via UnitedHealthcare Provider Portal or call 866-889-8054
  5. Track Status: Monitor through provider portal or member services
  6. Coordinate Specialty Pharmacy: Contact OptumRx at 800-310-6826 once approved
  7. Begin Treatment: Receive medication through REMS-certified specialty pharmacy

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all uses UHC PA Requirements
REMS Compliance Mandatory safety program FDA REMS Requirements
Specialty Pharmacy Must use designated network OptumRx: 800-310-6826
Diagnosis Codes ICD-10 required (e.g., C90.00) PA notification form
12-Month Authorization Standard approval period UHC policy

REMS Requirements

The Lenalidomide REMS program is mandatory before any UnitedHealthcare approval. Missing REMS documentation is among the most common denial reasons.

Essential REMS Components:

  • Prescriber certification with authorization number
  • Patient-Physician Agreement Form completion
  • Pregnancy testing for women of childbearing potential
  • Contraception counseling documentation
  • REMS-certified specialty pharmacy dispensing only
  • 28-day supply maximum with no automatic refills
Tip: REMS certification for new prescribers can take 1-2 weeks. Start this process early to avoid delays.

Common Denial Reasons & How to Fix Them

Denial Reason Solution Required Documentation
Missing REMS compliance Complete all REMS requirements REMS enrollment confirmation
Insufficient diagnosis documentation Submit detailed pathology reports ICD-10 codes, biopsy results, labs
Inadequate prior therapy records Detail all previous treatments Drug names, dates, outcomes
Off-label use without support Provide NCCN guidelines Peer-reviewed literature
Quantity limits exceeded Justify dosing clinically Physician letter with rationale

Clinician Corner: Medical Necessity Letter Checklist

When appealing a denial, include these elements in your medical necessity letter:

✓ Primary diagnosis with ICD-10 code and pathology confirmation
✓ Prior treatments with specific drug names, dates, and reasons for discontinuation
✓ Clinical rationale for Revlimid based on FDA labeling or NCCN guidelines
✓ Treatment goals and expected outcomes
✓ Contraindications to preferred alternatives
✓ Monitoring plan including lab schedule and safety measures

Appeals Process in Washington

Washington state provides strong consumer protections for insurance denials, including specialty medications like Revlimid.

Internal Appeals with UnitedHealthcare

Timeline: File within 180 days of denial notice Decision: 30 days for standard review, 72 hours for expedited How to Submit:

  • Online: UnitedHealthcare provider/member portal
  • Phone: Member services number on insurance card
  • Mail: Address provided in denial letter

External Review (IRO) Process

After internal appeal denial, Washington residents can request external review through an Independent Review Organization:

Eligibility: Available after exhausting internal appeals Timeline: File within 120 days of final internal denial Cost: Free to patient (insurer pays) Decision: 45 days for standard, 72 hours for expedited Outcome: IRO decision is binding on UnitedHealthcare

How to Request External Review:

  1. Submit request to Washington Office of the Insurance Commissioner (OIC)
  2. Include documentation: Denial letters, medical records, physician support
  3. OIC assigns IRO from approved list of medical specialists
  4. IRO reviews all evidence and makes independent determination

Contact: Washington OIC Consumer Advocacy: 1-800-562-6900

Note: If your employer plan is self-funded (ERISA), state external review may not apply. Contact the U.S. Department of Labor for ERISA appeals guidance.

Costs and Financial Assistance

UnitedHealthcare Specialty Pharmacy Costs

Revlimid costs vary by plan design:

  • Tier 3 specialty: Highest copay/coinsurance tier
  • Typical cost: $15,000+ per 28-day cycle (list price)
  • Patient responsibility: Varies by plan (copay vs. coinsurance)

Financial Assistance Programs

Bristol Myers Squibb Support:

  • Copay assistance for commercially insured patients
  • Coverage verification and reimbursement navigation
  • Visit BMS patient support

Independent Assistance:

  • Leukemia & Lymphoma Society: Co-pay assistance for blood cancers
  • Patient Advocate Foundation: CO-PAY RELIEF program
  • Blood Cancer United: Co-pay assistance program
From our advocates: "We've seen patients reduce their Revlimid costs from $3,000 monthly to under $100 by combining manufacturer copay cards with foundation assistance. The key is applying to multiple programs simultaneously, as many have different eligibility criteria and funding cycles."

Specialty Pharmacy Requirements

UnitedHealthcare requires Revlimid to be dispensed through their specialty pharmacy network, typically OptumRx specialty pharmacy.

Why Specialty Pharmacy?

  • REMS compliance: Only certified pharmacies can dispense
  • Cold chain storage: Maintains medication integrity
  • Patient monitoring: Tracks adherence and side effects
  • Insurance coordination: Streamlines prior authorization

Contact OptumRx: 800-310-6826 for prescription transfers and coordination

Renewal and Reauthorization

Timeline for Renewal

UnitedHealthcare typically authorizes Revlimid for 12-month periods. Plan renewal 90 days before expiration:

90 days before: Schedule prescriber appointment for updated clinical assessment 60 days before: Submit renewal prior authorization with current labs and imaging 30 days before: Follow up on approval status to avoid treatment gaps

Required Renewal Documentation

  • Updated clinical notes showing treatment response
  • Recent laboratory results (CBC, metabolic panel)
  • Imaging studies demonstrating stable or improved disease
  • Documentation that patient tolerates treatment well

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Washington? Standard reviews take up to 30 days. Expedited reviews (when treatment delay would harm health) are completed within 72 hours.

What if Revlimid is non-formulary on my plan? Revlimid is on UnitedHealthcare's specialty formulary as Tier 3. If coverage is denied, request a formulary exception with medical necessity documentation.

Can I request an expedited appeal? Yes, if delaying Revlimid would jeopardize your health or cause severe pain. Expedited appeals are decided within 72 hours.

Does step therapy apply if I've tried other treatments outside Washington? Yes, prior therapy trials from any location count toward step therapy requirements. Provide complete documentation of all previous treatments.

What happens if my appeal is denied? You can request external review through Washington's IRO process. This independent medical review is binding on UnitedHealthcare and free to you.

How do I check my prior authorization status? Log into the UnitedHealthcare member portal or call the member services number on your insurance card for real-time status updates.

When to Escalate

Contact the Washington Office of the Insurance Commissioner if you experience:

  • Delays beyond stated timelines
  • Improper denial reasons
  • Difficulty accessing the appeals process
  • Concerns about UnitedHealthcare's handling of your case

Washington OIC: 1-800-562-6900 or insurance.wa.gov

The OIC can provide free assistance with appeals, investigate complaints, and ensure UnitedHealthcare follows Washington insurance laws.

About Counterforce Health: Counterforce Health specializes in turning insurance denials into successful appeals for patients, clinicians, and specialty pharmacies. Our platform analyzes denial letters and creates evidence-backed appeals that address payers' specific criteria, helping patients access critical medications like Revlimid more efficiently.

For complex cases requiring detailed appeal documentation, Counterforce Health can help craft targeted rebuttals that align with UnitedHealthcare's policies and Washington's regulatory requirements, increasing your chances of approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Insurance coverage and requirements may change; verify current policies with UnitedHealthcare and Washington state regulators.

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