By Counterforce Health Team in Revlimid (lenalidomide) —

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

Answer Box: Get Revlimid (lenalidomide) Covered by Aetna CVS Health in New Jersey

Yes, Aetna CVS Health covers Revlimid (lenalidomide) in New Jersey with prior authorization. Your fastest path to approval: 1) Confirm your prescriber and pharmacy are REMS-certified, 2) Submit complete prior authorization via Availity portal with diagnosis, clinical notes, and REMS documentation at least 2 weeks before treatment start, and 3) If denied, file internal appeal within 180 days. For external review after internal appeals, use New Jersey's IHCAP program through Maximus Federal Services (1-888-393-1062).

Start today: Contact your prescriber to begin REMS enrollment and gather prior therapy documentation for your PA submission.

Table of Contents

Coverage Requirements at a Glance

Requirement Details Where to Find It Source
Prior Authorization Required for all Aetna plans Aetna precertification list Aetna PA Requirements
Formulary Status Covered with PA approval 2024 NJ formulary Aetna NJ Formulary
REMS Enrollment Mandatory for prescriber, patient, pharmacy FDA REMS program BMS REMS Portal
Step Therapy May apply; exceptions available Clinical policy bulletins Aetna Clinical Policies
Submission Method Availity portal (Novologix for specialty) Provider resources Availity Portal
Processing Time 30-45 days standard; 72 hours expedited PA guidelines Aetna Processing Times

Step-by-Step: Fastest Path to Approval

1. Confirm REMS Enrollment (Patient & Prescriber)

Who does it: Patient and prescriber together
Documents needed: REMS enrollment forms, pregnancy test results (if applicable)
Timeline: 1-2 weeks before PA submission
Source: BMS REMS Patient Safety Portal

2. Gather Clinical Documentation

Who does it: Prescriber's office
Documents needed: Diagnosis confirmation (ICD-10), prior therapy records, lab results, clinical notes
Timeline: Concurrent with REMS enrollment
Key requirement: Document medical necessity for multiple myeloma, MDS with 5q deletion, or other FDA-approved indications

3. Submit Prior Authorization

Who does it: Prescriber
How to submit: Availity provider portal using Novologix for specialty drugs
Timeline: At least 2 weeks before intended start date
Required elements: Complete PA form, REMS documentation, clinical rationale

4. Track Decision Timeline

Standard review: 30-45 days
Expedited review: 72 hours (requires urgent medical justification)
Contact: Aetna Provider Precertification 1-888-632-3862 (Commercial), 1-800-624-0756 (Medicare)

5. If Approved: Coordinate Specialty Pharmacy

Pharmacy: CVS Specialty Pharmacy (Aetna's preferred specialty provider)
REMS verification: Pharmacy confirms all REMS requirements before dispensing
Supply limit: 28-day supply maximum per REMS requirements

6. If Denied: File Internal Appeal

Timeline: 180 days from denial date
Method: Written appeal with additional clinical documentation
Include: Point-by-point rebuttal addressing denial reasons

7. External Review (If Needed)

Program: New Jersey IHCAP through Maximus Federal Services
Contact: 1-888-393-1062
Timeline: File within 4 months of final internal denial
Decision: Binding on Aetna; 45 days standard, 48 hours urgent

REMS Program Compliance

Revlimid requires strict compliance with FDA's Risk Evaluation and Mitigation Strategy due to severe birth defects risk. All three parties must be enrolled before dispensing can occur.

Prescriber Requirements

  • Complete REMS certification training
  • Counsel patients on risks and safe use
  • Document pregnancy testing and contraception compliance
  • Verify patient understanding through signed agreements

Patient Requirements

All patients:

  • Sign Patient-Physician agreement form
  • Prohibited from donating blood or sperm during treatment and 4 weeks after

Female patients of reproductive potential:

  • Two forms of effective contraception
  • Pregnancy testing: before treatment, every 4 weeks during treatment, 4 weeks after discontinuation
  • Monthly REMS surveys confirming compliance

Male patients:

  • Use condoms during treatment and 4 weeks after (drug present in semen)
  • Partner pregnancy testing if partner is of reproductive potential

Pharmacy Requirements

  • REMS certification for dispensing
  • Verify active patient/prescriber enrollment before each fill
  • Maximum 28-day supply
  • No automatic refills

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
REMS non-compliance Submit proof of enrollment REMS enrollment confirmations, pregnancy test results
Off-label use Provide clinical justification Peer-reviewed studies, guideline citations (NCCN, FDA compendia)
Inadequate prior therapy Document treatment failures Chart notes showing prior therapies, dates, outcomes, intolerance
Missing clinical information Complete medical records Diagnosis confirmation, staging, lab results, treatment history
Step therapy requirement Request exception or document failures Prior authorization for step therapy exception with clinical rationale
Quantity limits exceeded Medical necessity for higher dose Dosing rationale, body surface area calculations, treatment protocol

Appeals Process for New Jersey Patients

Internal Appeals with Aetna CVS Health

Level 1 Internal Appeal

  • Timeline: 180 days from denial date
  • Decision time: 30 days standard, 72 hours expedited
  • Submission: Written appeal with new clinical evidence
  • Include: Point-by-point rebuttal, additional medical records, specialist letters

Level 2 Internal Appeal (if applicable)

  • Timeline: 60 days from Level 1 denial
  • Process: Independent medical review within Aetna
  • Enhanced documentation: Peer-reviewed literature, treatment guidelines

External Review: New Jersey IHCAP

After exhausting internal appeals, New Jersey residents can access the state's Independent Health Care Appeals Program (IHCAP).

Eligibility:

  • Completed all internal appeals with Aetna
  • Fully-insured New Jersey plan or NJ FamilyCare
  • Denial based on medical necessity or experimental/investigational determination

Process:

  • Administrator: Maximus Federal Services
  • Contact: 1-888-393-1062
  • Filing deadline: 4 months from final internal denial
  • Cost: Free to patients (insurers pay administrative costs)

Timeline:

  • Preliminary review: 5 business days
  • Full decision: 45 calendar days standard
  • Urgent cases: 48 hours
  • Decision: Binding on Aetna CVS Health

Required documents:

  • Completed IHCAP application
  • Copy of final internal denial letter
  • All relevant medical records
  • Specialist letter supporting medical necessity
  • Clinical rationale addressing each denial reason
From our advocates: We've seen New Jersey IHCAP reviews succeed when patients include a comprehensive specialist letter that directly addresses the insurer's denial reasoning while citing current treatment guidelines. One multiple myeloma patient's appeal was approved after their oncologist provided detailed documentation of prior therapy failures and referenced NCCN guidelines supporting lenalidomide as the appropriate next-line treatment.

Medical Necessity Letter Essentials

When appealing a Revlimid denial, your prescriber's medical necessity letter should include:

Patient Information Section

  • Full name, date of birth, Aetna member ID
  • Primary diagnosis with ICD-10 code (C90.00-C90.02 for multiple myeloma)
  • Disease stage and prognostic factors

Clinical Justification

  • FDA-approved indication: Confirm patient meets criteria for multiple myeloma, MDS with 5q deletion, or other approved uses
  • Prior therapies: Document previous treatments, response rates, progression dates, and reasons for discontinuation
  • Current clinical status: Recent lab values, imaging results, performance status
  • Treatment rationale: Why lenalidomide is medically necessary at this time

REMS Compliance Documentation

  • Confirmation of prescriber REMS enrollment
  • Patient REMS enrollment status
  • Pregnancy testing results and contraception plan (if applicable)
  • Pharmacy REMS certification

Supporting Evidence

  • Guidelines: Reference NCCN, ASCO, or other recognized treatment guidelines
  • Literature: Cite peer-reviewed studies supporting the treatment approach
  • Contraindications: Document why alternative therapies are inappropriate

Counterforce Health specializes in helping patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Their platform analyzes denial letters and creates targeted, evidence-backed rebuttals that address each payer's specific requirements, significantly improving approval rates for complex medications like Revlimid.

Cost-Saving Options

Manufacturer Support Programs

BMS Access Support

  • Copay assistance for commercially insured patients
  • Patient assistance program for uninsured/underinsured
  • Eligibility: Income and insurance requirements apply
  • Contact: BMS Access Support

Foundation Grants

  • Leukemia & Lymphoma Society: Copay assistance grants
  • CancerCare: Financial assistance for cancer patients
  • HealthWell Foundation: Disease-specific copay assistance

State Programs

  • New Jersey Pharmaceutical Assistance to the Aged and Disabled (PAAD): For seniors and disabled residents
  • New Jersey FamilyCare: Medicaid expansion program with prescription coverage

When to Escalate

Contact New Jersey Insurance Regulators

If you've exhausted appeals and believe Aetna violated coverage requirements:

New Jersey Department of Banking and Insurance (DOBI)

  • Consumer Hotline: 1-800-446-7467
  • IHCAP Questions: 1-888-393-1062
  • Website: NJ.gov DOBI

File a Formal Complaint

  • When to file: Improper denial processing, missed deadlines, failure to follow appeal procedures
  • Required documents: All correspondence, denial letters, appeal submissions, timeline documentation
  • Process: DOBI investigates and can order corrective action

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Revlimid in New Jersey? Standard processing is 30-45 days. Expedited reviews (for urgent medical situations) are completed within 72 hours. Submit at least 2 weeks before your intended start date.

What if Revlimid is not on Aetna's formulary? Revlimid is on Aetna's 2024 New Jersey formulary but requires prior authorization. If it were non-formulary, you could request a formulary exception with clinical justification.

Can I request an expedited appeal in New Jersey? Yes, both Aetna internal appeals and New Jersey IHCAP offer expedited review for urgent medical situations where delays could cause serious harm to your health.

Does step therapy apply if I started treatment outside New Jersey? Previous therapy within 365 days typically qualifies for automatic step therapy exceptions. Provide documentation of your prior treatment history with your PA submission.

What happens if IHCAP overturns Aetna's denial? The decision is binding on Aetna CVS Health. They must cover the treatment as ordered by the independent review organization. This is mandated by New Jersey statute N.J.S.A. 26:2S-11.

How much does Revlimid cost without insurance? List price typically exceeds $15,000 per 21-28 day cycle. This is why securing insurance coverage or manufacturer assistance is crucial for most patients.

Can my doctor file the IHCAP appeal for me? Yes, New Jersey allows providers to file external appeals on behalf of patients with proper consent. This can be helpful given the complexity of the documentation required.

What if I need Revlimid for an off-label use? Off-label uses require stronger clinical justification. Your prescriber should cite peer-reviewed literature, recognized drug compendia, and treatment guidelines supporting the off-label indication.

Important: This guide provides educational information and should not replace professional medical or legal advice. Coverage decisions depend on individual circumstances, policy terms, and clinical factors. For personalized guidance on your specific situation, consult with your healthcare provider and insurance plan directly.

For patients facing complex prior authorization challenges, Counterforce Health offers specialized support in converting insurance denials into successful appeals through evidence-based, payer-specific strategies.

Sources & Further Reading

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