By Counterforce Health Team in Revlimid (lenalidomide) —

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

Answer Box: Quick Path to Approval

To get Revlimid (lenalidomide) covered by Aetna (CVS Health) in New York: First, ensure your prescriber and pharmacy are enrolled in the mandatory Lenalidomide REMS program. Submit prior authorization through Aetna's provider portal with diagnosis codes, prior therapy documentation, and REMS certification numbers. If denied, file an internal appeal within 180 days, then pursue external review through New York's Department of Financial Services if needed. New York's strong appeal protections require insurers to continue coverage during the appeal process for certain single-source drugs like Revlimid.

Start today: Call Aetna member services at the number on your insurance card to check formulary status and initiate the prior authorization process.

Table of Contents

  1. Why New York State Rules Matter
  2. Turnaround Standards and Timelines
  3. Step Therapy Protections and Medical Exceptions
  4. Continuity-of-Care Protections
  5. External Review and Complaints Process
  6. Fastest Path to Approval: Step-by-Step
  7. Common Denial Reasons and Solutions
  8. Appeals Playbook for Aetna in New York
  9. Scripts and Practical Templates
  10. When to Escalate and Get Help

Why New York State Rules Matter

New York has some of the strongest insurance appeal protections in the country, which directly impact how Aetna (CVS Health) must handle Revlimid (lenalidomide) coverage decisions. Unlike federal-only protections, New York Insurance Law Section 4903 establishes specific timelines for utilization review decisions and creates binding external appeal rights through the Department of Financial Services.

For Revlimid specifically, New York's pending continuity-of-care legislation (Senate Bill S6168) would require insurers to maintain coverage of single-source drugs like Revlimid when formularies change, as long as therapy remains medically necessary. Even before this becomes law, many Aetna plans in New York already implement similar policies due to state oversight and federal requirements.

Key advantage for New York patients: If Aetna denies your Revlimid coverage and you file an appeal, they must often continue covering the drug at previous cost-sharing levels during the entire appeal process—not just for a brief transition period.

Turnaround Standards and Timelines

New York law requires specific response times that are often faster than federal minimums:

Decision Type New York Requirement Aetna's Typical Response
Non-urgent prior authorization 3 business days after receiving complete information 2-5 business days
Urgent/expedited decisions 72 hours (telephone notice) 24-72 hours
Retrospective review 30 days 30 days
Internal appeals 30 days for standard; 72 hours for urgent 30 days standard; 72 hours expedited
Note: If Aetna misses these deadlines, it's automatically considered an adverse determination, giving you immediate appeal rights under New York Insurance Law Section 4904.

Step Therapy Protections and Medical Exceptions

Aetna typically requires step therapy for Revlimid, meaning you must try preferred alternatives first. However, New York patients have strong override protections:

Medical Exception Criteria

You can bypass step therapy if:

  • Life-threatening condition that jeopardizes health or function
  • Current treatment course requires Revlimid without interruption
  • Preferred drugs are inappropriate due to:
    • Documented failure within past 365 days
    • Known contraindications or allergies
    • Significant adverse effects
    • Drug interactions

Required Documentation

Your prescriber should submit:

  • Clinical rationale letter detailing diagnosis and treatment history
  • Prior therapy summary with dates, doses, durations, and outcomes
  • Lab results showing disease status or drug tolerance issues
  • Specialist consultation notes if applicable
Tip: Aetna often grants exceptions more readily when you provide specific dates and outcomes of prior therapy failures, rather than general statements about "tried and failed."

Continuity-of-Care Protections

New York's proposed legislation and existing practices provide strong continuity protections for Revlimid patients:

When Formularies Change

If you're already stable on Revlimid and Aetna removes it from formulary or increases cost-sharing:

  • Continue coverage under same terms while medically necessary
  • Maintain coverage during appeals at previous cost-sharing levels
  • No forced switching without medical justification and appeal rights

Plan Transitions

When switching to a new Aetna plan:

  • Transition fills (typically 30 days) while prior authorization is processed
  • Grandfathering exceptions for patients stable on therapy
  • Expedited review for ongoing treatments

External Review and Complaints Process

New York's external appeal system through the Department of Financial Services provides binding review of Aetna denials:

When You're Eligible

  • After exhausting Aetna's internal appeal process
  • For denials based on medical necessity, experimental/investigational determinations, or out-of-network issues
  • Within 4 months of receiving final adverse determination

How to File

  1. Contact DFS Consumer Assistance: (800) 342-3736
  2. Submit online: DFS complaint portal
  3. Mail forms to: Department of Financial Services, 1 State Street, New York, NY 10004

Required Documents

  • Copy of Aetna's denial letter and internal appeal decision
  • Medical records supporting medical necessity
  • Prescriber's letter of support
  • External appeal form (available on DFS website)
Important: External appeal decisions are binding on Aetna. If the independent reviewer overturns the denial, Aetna must cover Revlimid and refund any appeal fees.

Fastest Path to Approval: Step-by-Step

Step 1: Verify REMS Compliance

Who: Prescriber and pharmacy Action: Ensure both are enrolled in the Lenalidomide REMS program Timeline: Must be completed before prescribing Documents: REMS certification numbers

Step 2: Check Aetna Formulary Status

Who: Patient or prescriber Action: Use Aetna's 2025 formulary tool Timeline: Before submission Documents: Insurance card, plan details

Step 3: Gather Clinical Documentation

Who: Prescriber's office Action: Compile diagnosis, prior therapies, lab results Timeline: 1-2 business days Documents: Pathology reports, treatment history, current labs

Step 4: Submit Prior Authorization

Who: Prescriber Action: Submit via Aetna provider portal or fax Timeline: 2-5 business days for decision Documents: PA form, clinical notes, REMS documentation

Step 5: Monitor Decision

Who: Patient and prescriber Action: Track status through Aetna portal or member services Timeline: Follow up if no response within required timeframe Documents: Confirmation numbers, reference IDs

Step 6: Appeal if Denied

Who: Patient or prescriber Action: File internal appeal within 180 days Timeline: 30 days for standard appeal decision Documents: Denial letter, additional clinical evidence

Step 7: Pursue External Review if Needed

Who: Patient Action: File with New York DFS within 4 months Timeline: Varies by urgency Documents: All prior correspondence, medical records

Common Denial Reasons and Solutions

Denial Reason Solution Required Evidence
REMS non-compliance Submit certification numbers Prescriber/pharmacy REMS enrollment proof
Missing diagnosis Provide specific ICD-10 codes Pathology reports (e.g., C90.0 for multiple myeloma)
Step therapy not met Request medical exception Prior therapy failure documentation
Not medically necessary Submit specialist letter NCCN guidelines, peer-reviewed studies
Quantity limits exceeded Justify dosing Weight-based calculations, specialist rationale
Non-formulary status Request formulary exception Lack of therapeutic alternatives documentation

Appeals Playbook for Aetna in New York

Internal Appeal Process

Deadline: 180 days from denial Submission: Aetna member portal, mail, or fax Decision timeline: 30 days (standard), 72 hours (expedited) Required documents:

  • Copy of denial letter
  • Additional clinical documentation
  • Prescriber's letter of medical necessity

Expedited Appeals

When to use: Health would be jeopardized by standard timeline Timeline: 72 hours for decision Criteria: Serious deterioration of health or function Contact: Call Aetna member services to request expedited review

External Review Through DFS

After: Internal appeal exhausted or concurrent for urgent cases Deadline: 4 months from final adverse determination Cost: Up to $25 (waived for financial hardship or Medicaid) Decision: Binding on Aetna

Scripts and Practical Templates

Patient Phone Script for Aetna

"I'm calling about prior authorization for Revlimid for multiple myeloma. My prescriber has submitted the request with REMS certification. Can you check the status and confirm what additional documentation is needed? My member ID is [number] and the prescription was submitted on [date]."

Medical Necessity Letter Template

"[Patient] has [specific diagnosis with ICD-10] and requires Revlimid based on [NCCN guidelines/FDA indication]. Prior therapies including [specific agents with dates] resulted in [specific outcomes]. Current disease status shows [lab values/imaging]. Revlimid is medically necessary because [clinical rationale]. Alternative agents are inappropriate due to [contraindications/prior failures]."

Peer-to-Peer Request Script

"I'd like to request a peer-to-peer review for Revlimid prior authorization denial. The patient has refractory multiple myeloma with documented progression on [prior agents]. I can provide additional clinical context and answer questions about medical necessity."

When to Escalate and Get Help

Contact New York Consumer Assistance

When to Call

  • Aetna misses required decision timelines
  • Denied coverage during appeal process
  • Unclear about appeal rights or procedures
  • Need help filing external review

What to Have Ready

  • Insurance card and member ID
  • Denial letters and correspondence
  • Medical records and prescriber contact
  • Timeline of events and prior communications

For complex cases involving multiple denials or urgent medical needs, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps patients, clinicians, and specialty pharmacies navigate the prior authorization and appeals process by identifying denial reasons and drafting point-by-point rebuttals aligned with each plan's specific requirements.

Frequently Asked Questions

How long does Aetna prior authorization take for Revlimid in New York? Standard decisions take 2-5 business days. Urgent requests must be decided within 72 hours under New York law. If Aetna misses these deadlines, it's automatically considered a denial you can appeal.

What if Revlimid isn't on Aetna's formulary? You can request a formulary exception by demonstrating medical necessity and lack of therapeutic alternatives. New York's continuity-of-care protections may help if you were previously covered.

Can I get expedited appeals for Revlimid denials? Yes, if the delay would jeopardize your health. Call Aetna member services to request expedited review, which must be decided within 72 hours in New York.

Does step therapy apply if I failed therapies outside New York? Prior therapy failures from other states count for step therapy exceptions. Provide documentation of dates, doses, and outcomes from your previous treatments.

What happens if Aetna changes their formulary mid-year? New York's proposed legislation would require continued coverage of single-source drugs like Revlimid at previous cost-sharing levels while medically necessary, even after formulary changes.

How much does external review cost in New York? Up to $25, which is waived for financial hardship or Medicaid enrollees. If the external reviewer overturns Aetna's denial, they must refund the fee.

Can my pharmacy help with the appeals process? Yes, especially specialty pharmacies familiar with REMS requirements. They can provide documentation of proper certification and coordinate with your prescriber for appeals.

What if my employer plan is self-funded? Self-funded ERISA plans aren't subject to New York insurance law. Contact the U.S. Department of Labor EBSA at (866) 444-3272 for guidance on federal appeal rights.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for the most current coverage information. For personalized assistance with complex appeals, consider consulting with organizations like Counterforce Health that specialize in insurance coverage advocacy.

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