By Counterforce Health Team in Revlimid (lenalidomide) —

How to Get Revlimid (Lenalidomide) Covered by Cigna in Georgia: Timeline, Appeals & Required Forms

Answer Box: Getting Revlimid (Lenalidomide) Covered by Cigna in Georgia

Cigna requires prior authorization for Revlimid (lenalidomide) with mandatory REMS compliance, diagnosis confirmation, and lab requirements. Standard approval takes up to 72 hours; expedited review available within 24 hours for urgent cases. If denied, you have 180 days for internal appeals, then 60 days for Georgia external review through the Department of Insurance.

First steps today:

  1. Verify your oncologist and pharmacy are REMS-certified
  2. Check if generic lenalidomide is preferred on your Cigna formulary
  3. Gather pathology reports, prior therapy records, and recent CBC labs

Table of Contents

  1. What Affects Approval Timeline
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Typical Outcomes
  6. If Denied: Appeal Process in Georgia
  7. Renewal Cycles & Reauthorization
  8. Timeline Visual & Key Milestones
  9. Time-Saving Tips for Faster Approval

What Affects Approval Timeline

Several factors determine how quickly Cigna processes your Revlimid (lenalidomide) prior authorization in Georgia:

Benefit Type & Plan Complexity

  • Commercial Cigna plans: Standard 72-hour review; expedited 24-hour for urgent cases
  • Cigna Medicare plans: 72 hours standard, 24 hours for fast decisions once prescriber statement received
  • Complex cases: Off-label uses or multiple prior failures may require additional clinical review

REMS Compliance Status

The Lenalidomide REMS program is federally mandated. Missing REMS certification causes automatic denial regardless of medical necessity. Both your prescriber and specialty pharmacy (often Accredo for Cigna) must be enrolled.

Documentation Completeness

Cigna's lenalidomide policy (CNF-541) requires specific clinical criteria. Incomplete submissions restart the review clock.

Pre-Submission Preparation (0-2 Days)

Essential Checklist

Patient Information:

  • Insurance ID and group number
  • Current weight and body surface area
  • ICD-10 diagnosis codes

Clinical Documentation:

  • Pathology report confirming multiple myeloma, MDS with del(5q), or other FDA-approved indication
  • Prior therapy history with dates, doses, and outcomes
  • Recent labs (within 14 days): CBC with ANC ≥500 cells/mm³, platelets ≥30,000/mm³
  • For MDS: serum erythropoietin level if applicable

REMS Verification:

  • Confirm prescriber enrollment at lenalidomiderems.com
  • Verify specialty pharmacy REMS status
  • Complete patient counseling requirements

Formulary Check

Most Cigna plans prefer generic lenalidomide over brand Revlimid. Check your specific formulary through the Cigna member portal or call the number on your insurance card. If Revlimid is non-formulary, you'll need a formulary exception with documented intolerance or failure of generic options.

Submission to Initial Review (1-5 Days)

How Cigna Reviews Lenalidomide Requests

First-Level Screening:

  1. REMS compliance verification
  2. Formulary status check (generic vs. brand preference)
  3. Basic eligibility (age ≥18, appropriate diagnosis)

Clinical Review Criteria: According to Cigna's policy, approval requires:

Indication Key Requirements
Multiple Myeloma Relapsed/refractory; prior therapy with proteasome inhibitor + immunomodulator; often combined with dexamethasone
MDS with del(5q) Confirmed cytogenetics; transfusion-dependent anemia; erythropoietin >500 mU/mL or ESA failure
Mantle Cell Lymphoma Relapsed/refractory; prior BTK inhibitor therapy

Submission Methods

  • Provider portal: Fastest option through Cigna's online system
  • Phone: 1-844-374-7377 for Express Scripts Medicare
  • Fax: Include completed PA form with all supporting documents

Additional Information Requests (1-7 Days)

If Cigna requests additional information, respond within 14 days to avoid case closure. Common requests include:

Missing Lab Values:

  • Updated CBC if >14 days old
  • Renal function tests for dosing adjustments
  • Liver function if indicated

Insufficient Prior Therapy Documentation:

  • Detailed treatment history with specific dates
  • Reason for discontinuation (progression, toxicity, intolerance)
  • Supporting imaging or lab evidence of treatment failure

REMS Compliance Issues:

  • Updated prescriber certification
  • Pharmacy enrollment confirmation
  • Patient counseling documentation
Tip: Proactively submit comprehensive documentation to avoid delays. Counterforce Health helps streamline this process by organizing clinical evidence and payer-specific requirements into targeted appeals that address each criterion systematically.

Decision Window & Typical Outcomes

Standard Approval Process

  • Initial review: Up to 72 hours for complete submissions
  • Expedited review: 24 hours for urgent cases where delay could jeopardize health
  • Approval duration: Typically 12 months with reauthorization required

Reading Your Approval Letter

Approved requests specify:

  • Covered indication and ICD-10 codes
  • Approved dosing regimen
  • Quantity limits (typically 25mg daily, days 1-21 of 28-day cycles)
  • Specialty pharmacy requirement
  • Reauthorization date

Common Denial Reasons

  1. REMS non-compliance (most common)
  2. Inadequate lab values (low ANC or platelets)
  3. Step therapy not met (generic lenalidomide not tried first)
  4. Off-label use without sufficient evidence
  5. Quantity limits exceeded without justification

If Denied: Appeal Process in Georgia

Internal Appeals with Cigna

Timeline for Filing:

  • 180 days from denial date for most commercial plans
  • Submit appeal letter with supporting documentation

Review Process:

  • Standard internal appeal: 30 days for decision
  • Expedited appeal: 72 hours for urgent cases
  • Second-level review available if first appeal denied

Georgia External Review Process

If Cigna's internal appeals are unsuccessful, Georgia law provides external review through the Georgia Department of Insurance.

Key Requirements:

  • 60-day deadline from final internal denial notice
  • No cost to patient
  • Binding decision on Cigna

Filing Process:

  1. Contact Georgia DOI Consumer Services: 1-800-656-2298
  2. Submit external review application with denial letters
  3. Include physician certification of medical necessity
  4. DOI assigns independent review organization (IRO)

Timeline:

  • Standard review: 45 days for decision
  • Expedited review: 20 days for experimental/investigational drugs
  • IRO assignment: Within 1 business day
Note: Georgia's external review has overturned many specialty drug denials when proper medical evidence is provided. Independent physicians review cases using current medical standards and guidelines.

Renewal Cycles & Reauthorization

When to Reauthorize

  • 12 months from initial approval date
  • Plan year changes (January 1st for most plans)
  • Dosing modifications requiring new quantity limits

Renewal Documentation

  • Updated labs showing stable blood counts
  • Oncologist assessment of continued benefit
  • No evidence of disease progression
  • Continued REMS compliance

Streamlined Renewals

For stable patients, renewals typically process faster than initial requests. Ensure your oncologist submits reauthorization 30 days before expiration to avoid treatment interruption.

Timeline Visual & Key Milestones

Phase Timeline Key Actions Potential Delays
Pre-submission 0-2 days REMS verification, document gathering Missing REMS enrollment
Initial submission Day 1 PA form submitted with complete documentation Incomplete clinical records
Cigna review 1-3 days Clinical criteria assessment Additional information requests
Decision 3-5 days Approval/denial notification Complex cases requiring peer review
If denied - Internal appeal 30 days Enhanced documentation, clinical justification Missing appeal deadline
External review (GA) 45 days Independent medical review Late filing (>60 days)

Time-Saving Tips for Faster Approval

Portal Usage

  • Use Cigna's provider portal for fastest submission
  • Electronic submissions process quicker than fax
  • Real-time status tracking available

Bundled Evidence Strategy

Submit comprehensive documentation upfront:

  • Complete treatment history in chronological order
  • All required labs in single submission
  • NCCN guideline references supporting requested use

Direct Specialty Routing

  • Work with Cigna-preferred specialty pharmacies (Accredo)
  • Leverage pharmacy's prior authorization support services
  • Coordinate REMS compliance through specialty pharmacy

Peer-to-Peer Review

For complex cases, request direct physician-to-physician discussion:

  • Available for denied cases
  • Allows real-time clarification of clinical rationale
  • Often resolves documentation gaps quickly

Frequently Asked Questions

How long does Cigna prior authorization take for Revlimid in Georgia? Standard review takes up to 72 hours once complete documentation is received. Expedited review is available within 24 hours for urgent cases.

What if Revlimid is not on my Cigna formulary? You can request a formulary exception. Your oncologist must document medical necessity and why generic lenalidomide alternatives are inappropriate.

Can I appeal if my REMS enrollment is delayed? REMS compliance is mandatory and non-negotiable. Focus on completing enrollment quickly rather than appealing. Contact lenalidomiderems.com for assistance.

Does step therapy apply to cancer drugs like Revlimid? Yes, Cigna may require trying generic lenalidomide before brand Revlimid, or other therapies before lenalidomide depending on your specific indication.

What happens if I miss the 60-day Georgia external review deadline? The deadline is strict. Contact Georgia DOI immediately if you're approaching the limit. Some plans may voluntarily allow longer timeframes, but don't rely on this.

Can I get temporary coverage while my appeal is pending? For urgent situations, request expedited review. Some plans offer transition supplies for formulary changes, but this varies by situation.

From Our Advocates

We've seen many Georgia patients successfully obtain Revlimid coverage after initial denials, particularly when the appeal included point-by-point responses to Cigna's specific policy criteria and comprehensive documentation of prior therapy failures. The key is often organizing complex medical records into a clear narrative that directly addresses each requirement in Cigna's lenalidomide policy.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for specialty medications like Revlimid. Our platform analyzes denial letters, identifies specific payer criteria, and helps clinicians craft comprehensive appeals that address each requirement systematically. By leveraging payer-specific workflows and evidence requirements, we help patients navigate complex prior authorization processes more effectively.

For additional support with Cigna denials or appeals in Georgia, visit www.counterforcehealth.org to learn how targeted appeals can improve approval rates for specialty oncology medications.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for specific coverage decisions and medical recommendations. Coverage policies and requirements may change; verify current information with Cigna and your healthcare team.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.