By Counterforce Health Team in Revlimid (lenalidomide) —

How to Get Revlimid (lenalidomide) Covered by Aetna (CVS Health) in Georgia: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Aetna (CVS Health) to Cover Revlimid (lenalidomide) in Georgia

Aetna (CVS Health) requires prior authorization for Revlimid (lenalidomide) in Georgia, typically approving FDA-labeled uses (multiple myeloma, MDS with del[5q], mantle cell lymphoma) when REMS compliance and clinical criteria are met. First step today: Have your oncologist submit Aetna's Medical Exception/PA form to the specialty pharmacy fax line with diagnosis, prior treatments, and NCCN guideline support. If denied, you have 180 days to appeal internally and can request Georgia Department of Insurance external review within 60 days of final denial.

Table of Contents

  1. Aetna (CVS Health) Policy Overview
  2. FDA Indication Requirements
  3. Step Therapy and Exceptions
  4. Quantity Limits and REMS Requirements
  5. Required Diagnostics and Documentation
  6. CVS Specialty Pharmacy Requirements
  7. Evidence for Medical Necessity
  8. Appeals Process in Georgia
  9. Cost Support Options
  10. Common Denial Reasons and Fixes
  11. FAQ

Aetna (CVS Health) Policy Overview

Aetna (CVS Health) covers Revlimid (lenalidomide) across commercial, exchange, and Medicare Advantage plans in Georgia, but prior authorization is mandatory. The drug appears on Aetna's 2024 precertification list and requires specialty pharmacy dispensing through CVS Specialty.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Aetna plans Aetna PA Policy 2232-A
Formulary Tier Specialty tier (high copay) Plan-specific drug guide
Step Therapy Plan-dependent; often requires prior MM therapy PA form and plan documents
Quantity Limits 21-28 capsules per 28-day cycle CVS Specialty guidelines
REMS Program Mandatory enrollment for all parties Lenalidomide REMS
Specialty Pharmacy CVS Specialty preferred Member portal or ID card

FDA Indication Requirements

Aetna (CVS Health) generally approves Revlimid for FDA-labeled indications documented in clinical policy 2232-A:

Approved Indications

Multiple Myeloma

  • Newly diagnosed MM (with dexamethasone, non-transplant eligible)
  • Relapsed/refractory MM after ≥1 prior therapy
  • Maintenance therapy post-autologous stem cell transplant

Myelodysplastic Syndromes (MDS)

  • Transfusion-dependent anemia
  • Low/intermediate-1 risk by IPSS
  • Confirmed del(5q) cytogenetic abnormality

Mantle Cell Lymphoma

  • Relapsed/progressed after 2 prior therapies
  • One prior therapy must include bortezomib

Required Documentation

  • Pathology report confirming diagnosis
  • Disease staging and risk stratification
  • ICD-10 codes (C90.00 for MM, D46.20 for MDS, C83.10 for MCL)
  • Prior treatment history with dates and outcomes

Step Therapy and Exceptions

Many Aetna plans require documentation of prior therapy failure before approving Revlimid, though specific step therapy requirements vary by employer group and plan design.

Typical Step Therapy Requirements

Multiple Myeloma (First-Line)

  • May require trial of proteasome inhibitor-based regimen OR
  • Clinical rationale why alternatives are inappropriate

Relapsed/Refractory MM

  • Documentation of ≥1 prior therapy (proteasome inhibitor, immunomodulatory drug, or anti-CD38 antibody)
  • Response assessment and reason for discontinuation

Medical Exception Process

If step therapy applies to your plan, your oncologist can request an exception by documenting:

  1. Prior treatment failures (specific drugs, dates, duration, response)
  2. Contraindications to preferred alternatives
  3. Intolerance to required first-line therapies
  4. Clinical urgency requiring immediate lenalidomide therapy

Submit exceptions using Aetna's Medical Exception form to the specialty pharmacy fax line listed in Aetna's Pharmacy FAQs.

Quantity Limits and REMS Requirements

Quantity Limits

  • Maximum: 28-day supply (21-28 capsules depending on dosing schedule)
  • No automatic refills: Each cycle requires new authorization
  • Dose modifications: Documented based on toxicity or renal function

REMS Program Compliance

The Lenalidomide REMS program is mandatory and non-negotiable:

Prescriber Requirements

  • REMS certification and enrollment
  • Patient counseling documentation
  • Authorization number for each prescription

Patient Requirements

  • REMS enrollment and signed Patient-Physician Agreement
  • Pregnancy testing (if applicable) and contraception compliance
  • Safe handling and disposal education

Pharmacy Requirements

  • REMS-certified specialty pharmacy only
  • Verification of all REMS elements before dispensing
Critical: Missing any REMS element results in automatic denial, regardless of medical necessity.

Required Diagnostics and Documentation

Baseline Requirements

  • CBC with differential (within 30 days)
  • Comprehensive metabolic panel including creatinine clearance
  • Pregnancy test for women of reproductive potential (within 10-14 days)
  • Bone marrow biopsy with cytogenetics (MM, MDS)
  • Flow cytometry/immunohistochemistry (lymphoma cases)

Ongoing Monitoring

  • Weekly CBC for first 8 weeks, then every 2 weeks for 8 weeks, then monthly
  • Monthly pregnancy testing (if applicable)
  • Renal function monitoring for dose adjustments

Clinical Documentation Tips

  • Include ECOG performance status and comorbidity assessment
  • Document transfusion requirements for MDS cases
  • Provide treatment goals and expected duration
  • Attach recent imaging studies showing disease status

CVS Specialty Pharmacy Requirements

Aetna (CVS Health) typically requires dispensing through CVS Specialty for Revlimid:

Enrollment Process

  1. Provider submits PA approval to CVS Specialty
  2. Patient enrollment in CVS Specialty program
  3. REMS verification for all parties
  4. Insurance benefit verification and copay calculation
  5. First fill coordination with oncology team

Shipping and Refills

  • Standard shipping: 7-10 business days after approval
  • Express shipping: Available for urgent cases
  • Refill reminders: CVS Specialty coordinates with prescriber for REMS renewals

For enrollment, call CVS Specialty at the number on your Aetna ID card or use the member portal.

Evidence for Medical Necessity

When Aetna requests additional clinical justification, include evidence from these verifiable sources:

Primary Evidence Sources

Supporting Documentation

  • Peer-reviewed studies supporting your specific indication
  • Treatment response criteria (IMWG for MM, IWG for MDS)
  • Biomarker results (del[5q] for MDS, high-risk cytogenetics)

For Counterforce Health, our platform helps clinicians identify the most relevant evidence for each payer's specific criteria, turning insurance denials into targeted, evidence-backed appeals that align with plan policies.

Appeals Process in Georgia

Internal Appeals with Aetna

Timeline: 180 days from denial notice to file appeal

Standard Review: 30-45 days for decision
Expedited Review: 72 hours for urgent cases

Required Documents:

  • Original denial letter
  • Detailed medical necessity letter from oncologist
  • Updated clinical notes and lab results
  • Relevant treatment guidelines and studies

Submit appeals through Aetna's member portal or mail to the address in your denial letter.

Georgia External Review

If Aetna upholds the denial, Georgia residents can request independent external review through the Georgia Department of Insurance.

Key Details:

  • Deadline: 60 days from final internal denial
  • Cost: Free to consumers
  • Timeline: 30 business days (72 hours if expedited)
  • Decision: Binding on Aetna

How to File:

  1. Complete Georgia external review application
  2. Submit all medical records and appeal documents
  3. Include prescriber letter explaining medical necessity
  4. Contact Georgia DOI Consumer Services at 1-800-656-2298 for assistance
Georgia Advantage: The state's external review process has helped many patients overturn wrongful denials for specialty medications when proper clinical evidence is provided.

Cost Support Options

Manufacturer Support

  • Bristol Myers Squibb Patient Assistance: Income-based free drug program
  • Revlimid Co-pay Card: Reduces out-of-pocket costs for eligible patients
  • Foundation Support: Organizations like CancerCare and Leukemia & Lymphoma Society

State and Federal Programs

  • Georgia Medicaid: Limited coverage for qualifying low-income patients
  • Medicare Extra Help: Prescription drug cost assistance
  • 340B Program: Discounted pricing at qualifying hospitals and clinics

Contact your oncology team's financial counselor to explore all available options.

Common Denial Reasons and Fixes

Denial Reason Solution Required Documentation
REMS non-compliance Complete enrollment REMS authorization number
Off-label use Provide guideline support NCCN or peer-reviewed evidence
Insufficient prior therapy Document treatment history Dates, responses, toxicities
Missing diagnostics Submit required labs CBC, CrCl, pregnancy test
Quantity exceeded Justify dosing Physician rationale for dose
Not medically necessary Clinical appeal Detailed medical letter

For complex appeals, services like Counterforce Health can help draft point-by-point rebuttals that address each denial reason with appropriate clinical evidence.

FAQ

How long does Aetna (CVS Health) prior authorization take in Georgia?
Standard PA decisions typically take 15-30 days. Expedited reviews for urgent cases are completed within 72 hours.

What if Revlimid is non-formulary on my plan?
Request a formulary exception using Aetna's Medical Exception form with clinical justification for why formulary alternatives are inappropriate.

Can I get an expedited appeal if my cancer is progressing?
Yes. Have your oncologist document that delay could seriously jeopardize your health or ability to regain function.

Does step therapy apply if I failed treatments in another state?
Yes, prior treatment history from any location counts toward step therapy requirements if properly documented.

What happens if CVS Specialty can't dispense due to REMS issues?
Contact your prescriber immediately to resolve REMS compliance. The pharmacy cannot override REMS requirements.

How much does Revlimid cost with Aetna coverage?
Specialty tier copays vary by plan but can range from $100-500+ per month. Check your specific plan documents or call member services.

Can I use a different specialty pharmacy besides CVS?
Some Aetna plans allow other REMS-certified specialty pharmacies, but CVS Specialty is typically preferred and may have better coverage terms.

What if I need Revlimid for an off-label indication?
Submit strong clinical evidence from NCCN guidelines or peer-reviewed literature supporting the off-label use for your specific condition.

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 plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For additional help navigating insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services or consider working with specialized appeal services.

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