By Counterforce Health Team in Revlimid (lenalidomide) —

Getting Revlimid (Lenalidomide) Covered by Humana in New York: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Revlimid Covered by Humana in New York

Humana requires prior authorization for Revlimid (lenalidomide) and REMS certification compliance. Start by ensuring your prescriber and pharmacy are REMS-certified, then submit a PA request through Humana's provider portal with complete clinical documentation. If denied, you have 65 days to appeal internally, then can request external review through New York State DFS within 4 months. For urgent cases, expedited reviews are available in 24-72 hours.

First step today: Verify REMS certification status and gather your complete treatment history before your prescriber submits the PA request.

Table of Contents

  1. Understanding Humana's Revlimid Requirements
  2. Reading Your Denial Letter
  3. Common Fixable Issues
  4. First-Level Appeal Process
  5. Peer-to-Peer Review Strategy
  6. External Appeals in New York
  7. Appeal Letter Templates
  8. Tracking and Documentation
  9. Cost Assistance Options
  10. When Other Options Fail

Understanding Humana's Revlimid Requirements

Revlimid (lenalidomide) is a specialty immunomodulatory drug manufactured by Bristol Myers Squibb, with an average wholesale cost of $18,723-$24,963 per 28-day cycle depending on dosing. Humana Medicare Advantage plans require both prior authorization and strict REMS (Risk Evaluation and Mitigation Strategy) compliance before coverage.

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all Revlimid prescriptions Complete PA form with clinical justification Humana PA Portal
REMS Certification Prescriber AND pharmacy must be certified REMS enrollment confirmation numbers FDA REMS Program
Diagnosis Documentation ICD-10 codes for approved indications Pathology reports, staging information Medical records
Prior Therapy History Documentation of previous treatments Treatment summaries, response assessments Clinical notes
Combination Therapy Rituximab pairing required for FL/MZL Concurrent prescription documentation Treatment plan

FDA-Approved Indications for Revlimid

Revlimid is approved for:

  • Multiple myeloma (with dexamethasone, and maintenance post-transplant)
  • Myelodysplastic syndromes with del(5q) cytogenetic abnormality
  • Relapsed/refractory mantle cell lymphoma
  • Follicular lymphoma and marginal zone lymphoma (with rituximab) in previously treated adults

Reading Your Denial Letter

When Humana denies Revlimid coverage, the denial letter will specify the exact reason. Common denial codes include:

Medical Necessity Denials:

  • Insufficient clinical documentation
  • Lack of prior therapy failure documentation
  • Missing combination therapy requirements (e.g., rituximab for FL/MZL)

Administrative Denials:

  • REMS non-compliance (prescriber or pharmacy not certified)
  • Missing authorization confirmation numbers
  • Incorrect dosing or quantity requests

Policy-Based Denials:

  • Step therapy requirements not met
  • Preference for generic lenalidomide over brand Revlimid
  • Non-formulary status requiring exception
Tip: Look for the specific denial code and reference it directly in your appeal. This shows you understand the exact issue that needs addressing.

Common Fixable Issues

Before filing an appeal, check these common problems that can be resolved quickly:

REMS Compliance Issues

  1. Verify prescriber certification - Check the FDA REMS database
  2. Confirm pharmacy enrollment - Ensure your dispensing pharmacy is REMS-certified
  3. Obtain confirmation numbers - Both prescriber and pharmacy need current confirmation numbers

Missing Clinical Documentation

  • Complete pathology reports with specific diagnosis
  • Staging information for multiple myeloma or lymphoma
  • Prior treatment history with specific drug names, doses, and response
  • Current disease status and progression markers

Coding and Administrative Errors

  • Verify ICD-10 diagnosis codes match approved indications
  • Check NDC/J-codes for correct formulation
  • Confirm quantity and days supply calculations

First-Level Appeal Process

Humana allows 65 days from the denial date to file your first internal appeal. Here's the step-by-step process:

Step 1: Gather Required Documentation

  • Original denial letter
  • Complete medical records supporting medical necessity
  • Prior authorization form (if not previously submitted)
  • REMS certification documentation
  • Prescriber letter of medical necessity

Step 2: Submit Your Appeal

Online: Through Humana member portal By Mail: Address provided on denial letter By Fax: Number specified in denial notice (verify current number)

Step 3: Include Medical Necessity Letter

Your prescriber should write a detailed letter addressing:

  • Specific diagnosis with ICD-10 codes
  • Previous treatments attempted and outcomes
  • Clinical rationale for Revlimid
  • Expected treatment duration and monitoring plan
  • Why formulary alternatives are inappropriate

Peer-to-Peer Review Strategy

If your initial appeal is denied, request a peer-to-peer review where your prescriber speaks directly with Humana's medical director.

Scheduling the Call

Contact Humana's provider services line and request a peer-to-peer review for the denied prior authorization. Have your case reference number ready.

Preparation Checklist for Prescribers

  • Patient's complete treatment history
  • Current disease status and progression markers
  • Specific contraindications to formulary alternatives
  • Relevant clinical guidelines (NCCN, ASH, ESMO)
  • Expected outcomes with Revlimid therapy

Key Talking Points

  1. Medical necessity: Why Revlimid is the most appropriate treatment
  2. Prior failures: Specific reasons other treatments didn't work
  3. Clinical urgency: Timeline for treatment initiation
  4. Guidelines support: Reference to evidence-based recommendations

External Appeals in New York

New York offers robust consumer protections through the Department of Financial Services external appeal process.

When to File External Appeals

  • After Humana issues a final internal denial
  • Within 4 months of the final denial date
  • For denials based on medical necessity, experimental/investigational designation, or out-of-network coverage

Timeline and Process

Standard Review: Decision within 72 hours Expedited Review: Decision within 24 hours for urgent drug needs Cost: $25 per appeal (waived for Medicaid enrollees or financial hardship)

Required Documentation

Note: New York's external appeals have a strong track record for specialty drug approvals when medical necessity is well-documented.

Appeal Letter Templates

Medical Necessity Letter Template

[Provider Letterhead]
[Date]

Humana Medicare Advantage
[Address from denial letter]

RE: [Patient Name], Member ID: [Number]
Request for Coverage: Revlimid (lenalidomide)

Dear Medical Director,

I am writing to appeal the denial of Revlimid (lenalidomide) for my patient [Name], who has [specific diagnosis with ICD-10 code].

CLINICAL HISTORY:
- Diagnosis: [Specific condition, stage, date of diagnosis]
- Prior therapies: [List all previous treatments with dates, doses, and outcomes]
- Current status: [Disease progression, current symptoms, functional status]

MEDICAL NECESSITY RATIONALE:
Revlimid is FDA-approved for [specific indication] and is the most appropriate treatment because:
1. [Specific clinical reason #1]
2. [Specific clinical reason #2]
3. [Why alternatives are not suitable]

SUPPORTING EVIDENCE:
- FDA labeling supports use for [indication]
- NCCN guidelines recommend [specific recommendation]
- Patient's REMS certification is current (Confirmation #: [number])

I respectfully request immediate approval of this medically necessary treatment.

Sincerely,
[Prescriber name and credentials]
[REMS certification number]

Patient Appeal Letter Template

[Date]

Humana Member Appeals
[Address from denial letter]

RE: Appeal for Revlimid (lenalidomide) Coverage
Member: [Your name], ID: [Member number]

Dear Appeals Review Team,

I am appealing your denial of coverage for Revlimid (lenalidomide), which my doctor has prescribed for my [condition]. 

My doctor has determined this medication is medically necessary because [brief explanation]. I have tried other treatments including [list previous therapies] without success.

I am requesting that you:
1. Review the additional medical documentation I am including
2. Approve coverage for Revlimid as prescribed
3. Process this appeal on an expedited basis due to my medical condition

Enclosed you will find:
- My doctor's letter of medical necessity
- Medical records supporting this request
- Documentation of previous treatment failures

Thank you for your prompt consideration.

Sincerely,
[Your signature and printed name]

Tracking and Documentation

Appeal Tracking Log

Keep detailed records of all communications:

Date Contact Method Person Spoken To Reference Number Action Taken Follow-up Date

Required Documentation Checklist

  • Original denial letter
  • Appeal form completed
  • Medical necessity letter from prescriber
  • Complete medical records
  • REMS certification documentation
  • Prior therapy history
  • Current lab results and imaging
  • Copies of all submissions

Cost Assistance Options

While working through the appeals process, explore these cost assistance programs:

Bristol Myers Squibb Access Support

  • Patient assistance programs for eligible patients
  • Copay support for commercially insured patients
  • Appeals assistance including template letters
  • Contact: BMS Access Support website

Foundation Support

  • Leukemia & Lymphoma Society copay assistance
  • Patient Advocate Foundation
  • CancerCare Financial Assistance Program

State Programs in New York

New York residents may qualify for additional state-funded prescription assistance programs through the New York State Department of Health.

When Other Options Fail

If appeals are unsuccessful, consider these alternatives:

Formulary Exception Requests

Request coverage of non-formulary Revlimid through Humana's exception process, requiring prescriber justification for why formulary alternatives are inappropriate.

Generic Lenalidomide

If brand Revlimid is denied but generic lenalidomide is covered, discuss with your prescriber whether the generic formulation is clinically appropriate.

Alternative Treatment Regimens

Work with your oncologist to explore covered alternative treatments that may be effective for your specific condition.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed appeals. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and develop compelling medical necessity arguments that align with each payer's specific criteria. Learn more at www.counterforcehealth.org.

Frequently Asked Questions

How long does Humana prior authorization take for Revlimid? Standard PA decisions are made within 72 hours. Expedited requests for urgent medical needs are processed within 24 hours when properly documented.

What if Revlimid is not on Humana's formulary? You can request a formulary exception with prescriber justification for medical necessity. The process is similar to prior authorization but requires additional documentation of why covered alternatives are inappropriate.

Can I get expedited appeals in New York? Yes. Both Humana internal appeals and New York State external appeals offer expedited processing (24-72 hours) when delay would jeopardize your health.

Does REMS certification affect coverage? Absolutely. Both your prescriber and dispensing pharmacy must be REMS-certified, and current confirmation numbers must be included with PA requests.

What happens if I start treatment while appealing? You'll be responsible for the full cost until coverage is approved. However, some appeals processes allow retroactive coverage if the appeal is successful.

How successful are external appeals in New York? New York's external appeal process has a strong track record for specialty drug approvals when medical necessity is well-documented and clinical guidelines support the treatment.

Get Help with Your Appeal

If you need assistance navigating Humana's appeals process in New York, contact:

  • Community Health Advocates: 888-614-5400 (free assistance for New Yorkers)
  • New York State Department of Financial Services: External Appeal Portal
  • Humana Member Services: Number on your insurance card

Remember, Counterforce Health can help streamline this entire process by creating targeted appeals that address your specific denial reasons and align with Humana's coverage policies.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact qualified professionals for assistance with insurance appeals. Coverage policies and procedures may change; verify current requirements with your specific plan.

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