By Counterforce Health Team in Revlimid (lenalidomide) —

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

Answer Box: Getting Revlimid Covered by Aetna (CVS Health) in Pennsylvania

Yes, Aetna (CVS Health) covers Revlimid (lenalidomide) in Pennsylvania with prior authorization for multiple myeloma, MDS, and mantle cell lymphoma. Your prescriber must submit a PA request with diagnosis, prior treatments, and REMS certification. If denied, Pennsylvania's new external review program overturns about 50% of appeals. Start today: Have your doctor check REMS enrollment status and submit the PA request through Aetna's provider portal or by fax.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Medical Necessity Criteria
  5. Costs and Financial Assistance
  6. Denials and Appeals
  7. REMS Requirements
  8. Specialty Pharmacy Transfer
  9. Troubleshooting Common Issues
  10. FAQ

Coverage Basics

Is Revlimid Covered by Aetna (CVS Health)?

Yes, Revlimid requires prior authorization for all FDA-approved indications including multiple myeloma (with dexamethasone and maintenance post-transplant), myelodysplastic syndromes with del(5q), relapsed/refractory mantle cell lymphoma, and follicular/marginal zone lymphoma (with rituximab).

Coverage applies to both commercial plans and Medicare Advantage plans administered by Aetna. However, specific formulary placement and cost-sharing vary by plan type.

Which Plans Cover Revlimid?

  • Commercial plans: Standard, Advanced Control, and Basic Control formularies
  • Medicare Advantage: Part D formulary with quantity limits
  • Medicaid managed care: State-specific formularies (verify with plan)
Note: Self-funded employer plans may have different coverage rules. Check with your HR department to confirm if your plan is insured or self-funded.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. REMS Enrollment (1-2 days)
    • Prescriber and pharmacy must be certified in the Revlimid REMS program
    • Complete training and patient agreements
    • Obtain authorization confirmation number
  2. Gather Documentation (Same day)
    • Pathology report confirming diagnosis
    • ICD-10 codes for indication
    • Prior treatment history with outcomes
    • Current labs (CBC, comprehensive metabolic panel, pregnancy test if applicable)
  3. Submit PA Request (Same day)
    • Use Aetna's provider portal or fax precertification form
    • Include all required documentation
    • Request expedited review if urgent
  4. Follow Up (1-3 days)
    • Check portal for status updates
    • Respond promptly to any requests for additional information
  5. Receive Decision (3-15 days)
    • Standard decisions: up to 15 days
    • Expedited decisions: within 72 hours

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all indications Aetna formulary documents
REMS Certification Prescriber and pharmacy must be enrolled BMS REMS portal
Quantity Limits 21-28 capsules per 28 days Plan-specific formulary
Step Therapy May require prior PI or IMiD trial PA determination form

Timing and Deadlines

How Long Does Aetna Prior Authorization Take?

  • Standard review: Up to 15 calendar days from complete submission
  • Expedited review: Within 72 hours for urgent medical needs
  • Incomplete submissions: Additional 14 days once missing information provided

When to Request Expedited Review

Request expedited processing if:

  • Patient is hospitalized
  • Treatment delay could seriously jeopardize health
  • Current therapy has failed and immediate alternative needed
  • Applying the standard timeframe could seriously jeopardize life or health

Medical Necessity Criteria

What Counts as Medical Necessity for Revlimid?

Aetna requires documentation of:

  1. Confirmed diagnosis with appropriate pathology/cytogenetics
  2. FDA-labeled indication or evidence-based off-label use
  3. Prior therapy requirements met (varies by indication)
  4. Contraindications ruled out (pregnancy, severe renal impairment)
  5. Appropriate dosing based on indication and renal function

Clinician Corner: Medical Necessity Letter Checklist

Your prescriber should include:

  • Problem statement: Specific diagnosis with ICD-10 code
  • Prior treatments: Previous therapies tried, duration, and outcomes
  • Clinical rationale: Why Revlimid is appropriate now
  • Guideline support: Reference to NCCN, ASCO, or FDA labeling
  • Monitoring plan: Lab schedule and safety assessments
  • Dosing justification: Dose selection based on indication/renal function

Costs and Financial Assistance

What Will Revlimid Cost Me?

Revlimid costs vary significantly by plan:

  • Wholesale Acquisition Cost: $18,723-$24,963 per 28-day cycle
  • Your cost: Depends on formulary tier, deductible, and copay assistance

Cost-Saving Options

  1. PrudentRx Copay Program (CVS Specialty patients)
    • May reduce cost to $0 if your plan participates
    • Automatic enrollment for eligible prescriptions
  2. Bristol Myers Squibb Access Support
    • Copay assistance for commercially insured patients
    • May reduce cost to $0 per prescription
    • Not available for government insurance (Medicare/Medicaid)
  3. Patient Assistance Programs
    • Income-based free medication programs
    • Contact BMS Access Support at 1-800-861-0048
Tip: If you have commercial insurance through CVS Caremark, you may automatically qualify for the PrudentRx program, potentially reducing your out-of-pocket cost to $0.

Denials and Appeals

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
REMS non-compliance Ensure prescriber and pharmacy REMS certification; include confirmation number
Missing diagnosis documentation Submit pathology report and ICD-10 codes
Step therapy not met Document prior therapy failures or contraindications
Non-formulary status Request formulary exception with medical necessity
Quantity limit exceeded Justify dosing with FDA labeling or guidelines

Appeals Playbook for Aetna (CVS Health) in Pennsylvania

Level 1: Internal Appeal

  • Timeline: 180 days from denial notice
  • Decision time: 30 days (72 hours if expedited)
  • How to submit: Aetna member portal or call member services
  • Required: Copy of denial letter, supporting medical records

Level 2: Pennsylvania External Review

  • Who's eligible: Commercial plan members (not self-funded plans)
  • Timeline: 4 months after final internal denial
  • Decision time: 45 days standard, 72 hours expedited
  • Success rate: About 50% of appeals overturned in 2024
  • How to submit: Pennsylvania Insurance Department website
  • Cost: Free
From our advocates: We've seen cases where initial Revlimid denials were overturned simply by including the REMS confirmation number and a clear summary of prior treatment failures. The key is thoroughness—don't assume the reviewer knows your medical history.

When to Escalate

Contact the Pennsylvania Insurance Department Consumer Help Center at 1-877-881-6388 if:

  • Aetna doesn't respond within required timeframes
  • You need help understanding the external review process
  • You believe your rights have been violated

REMS Requirements

What is the Revlimid REMS Program?

The Risk Evaluation and Mitigation Strategy is an FDA-required safety program due to Revlimid's risk of birth defects. Both your prescriber and pharmacy must be certified before you can receive the medication.

REMS Requirements Checklist

For prescribers:

  • Complete REMS training and enrollment
  • Ensure patient pregnancy prevention counseling
  • Maximum 28-day supply per prescription
  • No automatic refills allowed

For pharmacies:

  • REMS program certification
  • Verify authorization confirmation number
  • Confirm patient REMS enrollment before dispensing

For patients:

  • Sign Patient-Physician agreement
  • Comply with pregnancy prevention requirements
  • Understand embryo-fetal risks

Specialty Pharmacy Transfer

Why Was My Prescription Transferred to CVS Specialty?

Aetna often requires specialty medications like Revlimid to be filled through CVS Specialty Pharmacy for:

  • Enhanced clinical support and monitoring
  • Improved medication adherence programs
  • Access to manufacturer copay assistance programs
  • REMS program compliance oversight

Benefits of CVS Specialty

  • Dedicated pharmacists specializing in oncology
  • Automatic enrollment in cost-saving programs
  • Home delivery with temperature-controlled shipping
  • 24/7 clinical support hotline

Troubleshooting Common Issues

Portal Problems

  • Portal down? Call Aetna provider services at the number on your plan card
  • Missing forms? Download current PA forms from the provider portal
  • Login issues? Contact Aetna provider support for password reset

Documentation Issues

  • Missing records? Request from previous providers 2-3 weeks before PA submission
  • Lab results? Most recent CBC and CMP within 30 days of request
  • Prior therapy documentation? Include treatment dates, doses, and reason for discontinuation

REMS Complications

  • Prescriber not certified? Allow 3-5 business days for REMS enrollment
  • Pharmacy transfer needed? CVS Specialty can help coordinate REMS-certified pharmacy
  • Confirmation number missing? Contact BMS REMS support at 1-888-423-5436

FAQ

How long does Aetna prior authorization take in Pennsylvania? Standard PA decisions take up to 15 days; expedited reviews are completed within 72 hours. Pennsylvania law doesn't change Aetna's review timelines, but the state's external review process provides additional appeal rights.

What if Revlimid is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Include evidence that formulary alternatives are inappropriate due to contraindications, prior failures, or unique clinical circumstances.

Can I request an expedited appeal in Pennsylvania? Yes, both Aetna's internal appeals and Pennsylvania's external review offer expedited processes for urgent medical situations. Document why treatment delay could seriously jeopardize your health.

Does step therapy apply if I failed treatments outside Pennsylvania? Yes, treatment history from other states counts toward step therapy requirements. Provide documentation of prior therapies, including dates, doses, and reasons for discontinuation.

What if my employer plan is self-funded? Self-funded plans aren't subject to Pennsylvania's external review program. Contact your plan administrator directly for appeal rights, which are typically governed by federal ERISA law.

How do I know if my prescription needs REMS certification? All Revlimid prescriptions require REMS compliance. Your prescriber and pharmacy will be contacted by the REMS program to complete certification before dispensing.

Can I appeal if Aetna prefers generic lenalidomide? Yes, if brand Revlimid is medically necessary due to bioequivalence concerns, formulation differences, or documented intolerance to generic versions, you can request a brand exception.

What documents should I gather before starting? Insurance card, policy number, prescriber information, pathology reports, prior treatment records, recent lab results, and any previous denial letters or EOBs.

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Revlimid. Our platform analyzes denial letters, identifies the specific coverage barriers, and generates evidence-backed appeals that align with each payer's requirements. By combining clinical expertise with payer-specific knowledge, Counterforce Health helps patients, clinicians, and specialty pharmacies navigate the prior authorization process more effectively, reducing delays and improving approval rates for critical therapies.

For additional support with complex appeals or prior authorization challenges, Counterforce Health provides specialized assistance in crafting targeted, evidence-based responses to insurance denials.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For personalized assistance with Pennsylvania insurance appeals, contact the Pennsylvania Insurance Department Consumer Help Center at 1-877-881-6388.

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