By Counterforce Health Team in Revlimid (lenalidomide) —

How to Get Revlimid (lenalidomide) Covered by Blue Cross Blue Shield in Washington: Complete Forms & Appeals Guide

Answer Box: Getting Revlimid (lenalidomide) Covered by Blue Cross Blue Shield in Washington

Revlimid (lenalidomide) requires prior authorization from Blue Cross Blue Shield plans in Washington. The fastest path to approval: (1) Verify your plan covers lenalidomide (generic may be preferred over brand Revlimid), (2) Submit PA request through your plan's provider portal with clinical documentation, and (3) Ensure your prescriber and pharmacy are enrolled in the Lenalidomide REMS program. Start today: Call the member services number on your insurance card to confirm formulary status and get the correct PA form for your specific Blue Cross Blue Shield plan in Washington.

Table of Contents

  1. Start Here: Verify Your Plan & Coverage
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Online Access
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Enrollment
  6. Support Lines & Who to Contact
  7. Washington State Appeals & External Review
  8. Common Denial Reasons & Solutions
  9. Medical Necessity Letter Checklist
  10. Costs & Financial Assistance
  11. FAQ: Blue Cross Blue Shield Coverage in Washington

Start Here: Verify Your Plan & Coverage

Washington has multiple Blue Cross Blue Shield entities, each with different formularies and processes:

  • Premera Blue Cross (largest BCBS plan in Washington/Alaska)
  • Regence BlueShield (covers Washington, Oregon, Idaho, Utah)
  • Out-of-state BCBS plans for employees/retirees

Step 1: Identify Your Exact Plan

Check your insurance card for:

  • Plan name (Premera vs. Regence vs. other BCBS)
  • Pharmacy plan code (e.g., M1, M2, M4 for Premera)
  • Group number and member ID

Step 2: Check Formulary Status

Important: Many Blue Cross Blue Shield plans now prefer generic lenalidomide over brand Revlimid. Blue Cross Blue Shield of Michigan announced in 2025 they would stop covering brand Revlimid for most commercial members, requiring generic lenalidomide instead.

For Premera Blue Cross Washington plans:

  • Visit the Premera drug search tool
  • Enter "lenalidomide" or "Revlimid"
  • Look for "PA" (prior authorization required) designation

For Regence BlueShield:

  • Check your plan's formulary through your member portal
  • Note if lenalidomide is listed under "Drug Exclusions with Alternatives"

Prior Authorization Forms & Requirements

Premera Blue Cross Washington

Required for plans M1, M2, M4 when lenalidomide is not on the formulary:

Regence BlueShield Washington

Uses Medical Exception Criteria for excluded drugs with covered alternatives:

  • Must demonstrate medical necessity vs. formulary options
  • Annual renewal required with updated clinical documentation

Required Documentation for All Plans

  1. REMS Certification Confirmation
    • Prescriber REMS enrollment number
    • Patient REMS enrollment verification
    • Pharmacy REMS certification
  2. Clinical Documentation
    • Diagnosis with ICD-10 codes
    • Disease staging and risk factors
    • Prior therapies tried and outcomes
    • Contraindications to formulary alternatives
  3. Treatment Plan
    • Dosing schedule and duration
    • Monitoring plan
    • Expected clinical outcomes

Submission Portals & Online Access

Premera Blue Cross

  • Provider Portal: Premera provider pharmacy page
  • Online fax form available for group/HMO plans
  • Member Portal: Log in to check PA status and submit appeals

Regence BlueShield

  • Submit through Prime Therapeutics portal (Regence's pharmacy benefit manager)
  • Medical exception requests require prescriber submission
  • Member portal for status tracking
Tip: Save login credentials for both provider and member portals. PA status updates appear faster online than via phone.

Fax Numbers & Mailing Addresses

Premera Blue Cross Washington

  • Pharmacy PA Fax: 888-260-9836
  • Phone: 888-261-1756 (option 1 for providers, option 2 for patients)
  • Mailing Address (verify current address): Premera Blue Cross Pharmacy Services P.O. Box 91102 Seattle, WA 98111

General Blue Cross Blue Shield

  • Use plan-specific fax numbers on your PA forms
  • Include cover sheet with member ID, drug name, and urgency level

Cover Sheet Best Practices

  • Mark "URGENT" if treatment delay poses serious health risk
  • Include prescriber's direct phone for peer-to-peer review requests
  • List all attached documents (PA form, chart notes, lab results)

Specialty Pharmacy Enrollment

Revlimid/lenalidomide is restricted to REMS-certified specialty pharmacies only.

REMS-Certified Options in Washington

Enrollment Steps

  1. Prescriber: Complete Lenalidomide REMS certification
  2. Patient: Enroll in REMS program with pregnancy testing (if applicable)
  3. Pharmacy: Verify REMS certification and Blue Cross Blue Shield network status
  4. Coordination: Ensure all three parties are active before prescription submission
Note: Blue Cross Blue Shield of Michigan directs members to Walgreens Specialty when generic lenalidomide supply issues occur, suggesting strong network relationships.

Support Lines & Who to Contact

For Patients

  • Premera Member Services: Number on back of insurance card
  • Regence Member Services: Number on back of insurance card
  • BMS Access Support: Financial assistance and PA help

For Prescribers

  • Premera Provider Services: 888-261-1756
  • Peer-to-peer review: Request through PA portal or member services
  • REMS Support: BMS REMS Patient Safety site

What to Ask Member Services

  1. "Is brand Revlimid or generic lenalidomide covered on my formulary?"
  2. "What's my copay/coinsurance for lenalidomide through specialty pharmacy?"
  3. "Which specialty pharmacies are in-network for my plan?"
  4. "How do I check PA status online?"
  5. "What's the appeals process if my PA is denied?"

Washington State Appeals & External Review

Washington provides strong consumer protections for insurance denials through the Office of the Insurance Commissioner (OIC).

Internal Appeals Process

  • First Level: Submit through Blue Cross Blue Shield member portal or appeals address
  • Timeline: Varies by plan (typically 30-60 days)
  • Required: Complete internal appeals before external review

External Independent Review (IRO)

  • Eligibility: After internal appeals are exhausted or deemed final
  • How to Request: Submit request to your Blue Cross Blue Shield plan (not directly to OIC)
  • Timeline: 60 days from final internal denial to request external review
  • Decision Time: 20 days for fully-insured plans, 45 days for self-insured plans
  • Expedited Review: 72 hours for urgent cases

Washington OIC Consumer Support

  • Phone: 1-800-562-6900 (toll-free consumer advocacy line)
  • Services: Help with appeals, complaint filing, external review guidance
  • Authority: Can enforce appeal deadlines and procedural requirements
From our advocates: "We've seen Washington's external review process successfully overturn denials for specialty cancer medications when the internal appeal focused on medical necessity and cited NCCN guidelines. The key was submitting comprehensive clinical documentation within the 5-day window after IRO assignment."

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
REMS non-compliance Verify all parties enrolled REMS certification numbers, patient enrollment confirmation
Missing diagnosis details Submit complete clinical picture Pathology reports, staging, ICD-10 codes
Lack of rituximab pairing (FL/MZL) Confirm indication-specific regimen Treatment protocol, oncologist attestation
Generic available Request brand medical necessity Allergy documentation, prior generic failure
Step therapy required Document formulary failures Prior authorization records, intolerance notes

Counterforce Health can help streamline this process by analyzing your denial letter, identifying the specific coverage criteria, and drafting targeted appeals that address each payer requirement with the right clinical evidence and regulatory citations.

Medical Necessity Letter Checklist

Essential Elements

  • Patient identifiers: Name, DOB, member ID, plan type
  • Diagnosis: Specific condition (multiple myeloma, MDS, mantle cell lymphoma) with staging
  • Treatment history: Prior therapies tried, responses, discontinuation reasons
  • Current clinical status: Performance status, lab values, disease progression markers
  • Drug request: Exact medication, dose, schedule, duration

Clinical Justification

  • FDA approval: Confirm lenalidomide is FDA-approved for patient's indication
  • Guideline support: Reference NCCN guidelines for hematologic malignancies
  • Formulary alternatives: Document why covered options are inappropriate:
    • Prior failure or inadequate response
    • Contraindications or drug interactions
    • Intolerance or allergic reactions

Supporting Evidence

  • Recent clinic notes and lab results
  • Pathology and cytogenetics reports
  • Prior authorization decisions for previous treatments
  • Imaging studies showing disease status

Costs & Financial Assistance

Out-of-Pocket Estimates

  • Brand Revlimid: WAC pricing ~$18,723-$24,963 per 28-day cycle
  • Patient responsibility: Varies by plan's specialty tier (often 25-40% coinsurance)
  • Annual maximums: Check your plan's out-of-pocket limits

Financial Support Options

FAQ: Blue Cross Blue Shield Coverage in Washington

Q: How long does Blue Cross Blue Shield PA take in Washington? A: Premera processes standard requests within 72 hours, urgent requests within 24 hours. Regence timelines vary by plan type.

Q: What if lenalidomide is non-formulary on my plan? A: Submit a formulary exception request with medical necessity documentation. Focus on why formulary alternatives are inappropriate for your specific case.

Q: Can I request an expedited appeal in Washington? A: Yes, if treatment delay would seriously jeopardize your health. Mark requests as "URGENT" and provide clinical justification for expedited review.

Q: Does step therapy apply if I've failed treatments outside Washington? A: Prior therapy records from any state should count. Submit complete treatment history with dates, responses, and discontinuation reasons.

Q: What's the difference between Premera and Regence coverage? A: Both follow similar PA processes but have different formularies and specialty pharmacy networks. Check your specific plan's drug list and preferred pharmacies.

Q: How do I know if my prescriber is REMS-certified? A: Ask your oncologist's office directly, or verify through the BMS REMS Patient Safety website. Certification is required before any lenalidomide prescription.

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 about treatment decisions and verify current coverage details with your insurance plan. For personalized help with complex coverage challenges, Counterforce Health specializes in turning insurance denials into successful appeals through evidence-based advocacy and payer-specific expertise.

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