By Counterforce Health Team in Revlimid (lenalidomide) —

How to Get Revlimid (Lenalidomide) Covered by Aetna CVS Health in Michigan: Complete Prior Authorization Guide

Answer Box: Quick Path to Revlimid Coverage with Aetna CVS Health in Michigan

Revlimid (lenalidomide) requires prior authorization from Aetna CVS Health for multiple myeloma, MDS, and lymphoma indications. Your fastest path: ensure REMS program enrollment first, then submit PA via Aetna's Availity portal with diagnosis confirmation and treatment history. If denied, you have 60 days for internal appeal, then 127 days for Michigan DIFS external review. Start today: Call CVS Specialty at 800-237-2767 to begin REMS enrollment while your provider prepares PA documentation.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Documentation
  5. Submission Process
  6. CVS Specialty Pharmacy Setup
  7. After Submission: Tracking Your Request
  8. Appeals Process in Michigan
  9. Common Denial Reasons & Solutions
  10. Quick Reference Checklist

Who Should Use This Guide

This guide helps Michigan patients with Aetna CVS Health insurance get Revlimid (lenalidomide) covered for FDA-approved indications including:

  • Multiple myeloma (with dexamethasone or as maintenance post-transplant)
  • Myelodysplastic syndrome with deletion 5q
  • Relapsed/refractory mantle cell lymphoma
  • Follicular lymphoma and marginal zone lymphoma (with rituximab)

Expected outcome: With proper documentation and REMS compliance, most medically appropriate Revlimid requests are approved. BMS Access Support data shows many initial denials are overturned on appeal when proper evidence is provided.

Member & Plan Basics

Coverage Verification

Before starting, confirm your Aetna plan details:

Requirement What to Check Where to Find It
Active Coverage Policy effective dates, premium payments current Aetna member portal or ID card
Plan Type Commercial, Medicare, or Medicaid (affects PA process) Member services: 1-844-362-0934
Formulary Status Revlimid tier placement, step therapy requirements 2024 Precertification List
Specialty Pharmacy CVS Specialty required for REMS drugs Automatically routed for lenalidomide
Note: Aetna requires precertification for Revlimid in all diagnoses under Medicare plans, and specifically for multiple myeloma under commercial plans.

Clinical Criteria Requirements

Medical Necessity Standards

Your provider must document:

For Multiple Myeloma:

  • Confirmed MM diagnosis with pathology
  • Line of therapy (newly diagnosed, relapsed/refractory)
  • Prior treatment history and outcomes
  • Combination partner (dexamethasone for active disease)

For MDS with del(5q):

  • Cytogenetic confirmation of 5q deletion
  • Transfusion dependence or cytopenias
  • IPSS risk stratification

For Mantle Cell Lymphoma:

  • Relapsed/refractory disease after ≥1 prior therapy
  • Performance status and organ function

For FL/MZL:

  • Previously treated disease
  • Rituximab combination required (R² regimen)

REMS Program Compliance

Critical: Revlimid distribution is restricted under the Lenalidomide REMS program due to embryo-fetal toxicity risk.

Requirements:

  • Prescriber must be REMS-certified with valid authorization number
  • Pharmacy must be REMS-certified (CVS Specialty is pre-certified)
  • Patient enrollment with pregnancy prevention compliance (where applicable)
  • Confirmation numbers required on all prescriptions

Coding & Documentation

ICD-10 Diagnosis Codes

Use precise codes for your indication:

Condition ICD-10 Code Specificity
Multiple Myeloma C90.00 Not in remission
C90.01 In remission
C90.02 In relapse
MDS with 5q deletion D46.C Refractory anemia with 5q deletion
Mantle Cell Lymphoma C83.10-C83.19 Site-specific (unspecified to extranodal)
Follicular Lymphoma C82.0-C82.9 Grade and site-specific

Billing Information

  • HCPCS Code: J8999 (oral chemotherapy, not otherwise specified)
  • NDC Numbers: 59572-xxx-xx series (varies by strength: 5mg, 10mg, 15mg, 25mg capsules)
  • Units: Per capsule dispensed
  • Place of Service: 11 (office) or 19 (off-campus outpatient)

Submission Process

Step-by-Step PA Submission

1. REMS Enrollment (Patient & Prescriber)

2. Prior Authorization Request

  • Who: Prescriber or staff
  • Method: Aetna Availity portal (fastest) or fax
  • Timeline: Submit 2+ weeks before needed
  • Required: Diagnosis, treatment history, clinical notes

3. Documentation Package Include these elements in your PA request:

  • Confirmed diagnosis with ICD-10 code
  • Pathology/cytogenetics reports
  • Prior treatment summary (agents, dates, outcomes)
  • Current performance status and labs
  • Treatment plan and duration
  • REMS enrollment confirmation

Clinician Corner: Medical Necessity Letter

Essential components for your letter:

  • Problem Statement: Patient's specific diagnosis and disease status
  • Prior Treatments: Detailed history of previous therapies, including dates, doses, and reasons for discontinuation
  • Clinical Rationale: Why Revlimid is appropriate based on FDA labeling and guidelines (NCCN, ESMO)
  • Treatment Plan: Dosing schedule, combination partners, monitoring plan
  • Prognosis: Expected benefits and treatment goals

Key Guidelines to Reference:

  • FDA prescribing information for approved indications
  • NCCN Guidelines for specific malignancy
  • Disease-specific society recommendations (IMF, MDS Foundation)

CVS Specialty Pharmacy Setup

Since Revlimid requires REMS-certified dispensing, Aetna automatically routes to CVS Specialty.

Enrollment Process

Patient Information Needed:

  • Demographics (name, DOB, phone, address)
  • Insurance details (member ID, group number, BIN/PCN)
  • Clinical information (diagnosis, allergies, weight/height)
  • Prescriber details and REMS authorization number

Shipping Options:

  • Direct to patient (most common)
  • Provider office
  • Alternative address with patient consent

Contact Information:

After Submission: Tracking Your Request

Timeline Expectations

  • Standard PA Decision: 30-45 days from complete submission
  • Expedited Review: 72 hours (urgent cases with physician justification)
  • REMS Processing: 1-2 business days additional

Status Monitoring

Check PA status via:

  • Aetna provider portal (real-time updates)
  • Member services: 1-844-362-0934
  • CVS Specialty patient portal

Document Everything:

  • PA reference numbers
  • Submission dates
  • Representative names and call logs
  • Any requested additional information

Appeals Process in Michigan

Internal Appeals with Aetna

Timeline: 60 days from denial notice to file Decision: 30 days standard, 72 hours expedited How to File:

Required Documentation:

  • Copy of denial letter
  • Updated clinical information
  • Peer-reviewed literature supporting use
  • Provider attestation of medical necessity

Michigan External Review (DIFS)

If Aetna upholds the denial, Michigan patients have additional rights under the Patient's Right to Independent Review Act.

Key Details:

  • Filing Deadline: 127 days from final internal denial
  • Standard Review: Up to 60 days for decision
  • Expedited Review: 72 hours (pre-service denials threatening health)
  • Cost: No fee to patient
  • Decision: Binding on Aetna if favorable

How to File:

Required for Expedited Review:

  • Physician letter stating delay would harm patient
  • Pre-service denial only
  • Supporting clinical documentation
Tip: Michigan's DIFS is very consumer-friendly. Don't hesitate to call 877-999-6442 for help with forms or process questions.

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
REMS non-compliance Complete enrollment before resubmission REMS confirmation numbers, certified prescriber/pharmacy
Missing diagnosis details Provide specific pathology/cytogenetics Lab reports, bone marrow biopsy, flow cytometry
Step therapy not met Document prior failures or request override Treatment history, intolerance documentation, medical necessity letter
"Experimental/investigational" Cite FDA approval and guidelines FDA label, NCCN guidelines, peer-reviewed studies
Brand vs. generic preference Request formulary exception Clinical justification for brand necessity, allergy documentation

From Our Advocates

"We've seen many Michigan patients initially denied for Revlimid get approved on appeal by ensuring their REMS enrollment was complete and their provider included detailed prior treatment history. The key is demonstrating that Revlimid fits the FDA-approved indication and that alternative treatments have been tried or are inappropriate. Michigan's external review process through DIFS has been particularly effective for complex hematologic cases where the initial reviewer may not have specialized expertise."

Quick Reference Checklist

Before Submitting PA:

  • Patient enrolled in REMS program
  • Prescriber REMS-certified with authorization number
  • CVS Specialty pharmacy enrollment complete
  • Diagnosis confirmed with appropriate ICD-10 code
  • Prior treatment history documented
  • Clinical notes support medical necessity

PA Submission Package:

  • Completed PA form via Availity portal
  • Pathology/cytogenetics reports
  • Treatment history summary
  • Current lab values and performance status
  • Medical necessity letter with guideline references
  • REMS enrollment confirmation

If Denied:

  • File internal appeal within 60 days
  • Gather additional supporting evidence
  • Consider peer-to-peer review request
  • If upheld, file Michigan DIFS external review within 127 days
  • Contact patient advocacy groups for support

Cost Support Options:

  • BMS Access Support for copay assistance and PA templates
  • Patient Advocate Foundation for financial hardship cases
  • Leukemia & Lymphoma Society copay assistance program

About Coverage Support: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed rebuttals. Our platform analyzes denial letters and payer policies to identify the specific denial basis and draft point-by-point appeals aligned with each plan's requirements, incorporating the right clinical evidence and procedural details payers expect.

When navigating complex specialty drug approvals like Revlimid, having the right documentation and understanding payer-specific workflows can make the difference between approval and denial. Counterforce Health specializes in these challenging cases, helping ensure patients get access to the medications they need.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical advice. Coverage decisions depend on individual circumstances, plan specifics, and clinical factors. Always consult with your healthcare provider and insurance plan for personalized guidance. For assistance with Michigan insurance issues, contact DIFS at 877-999-6442.

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