By Counterforce Health Team in Revlimid (lenalidomide) —

How to Get Revlimid (Lenalidomide) Covered by Cigna in Ohio: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Revlimid Covered by Cigna in Ohio

Revlimid requires prior authorization from Cigna with mandatory REMS certification and diagnosis-specific clinical criteria. The fastest path to approval: (1) Verify your prescriber and pharmacy are REMS-certified, (2) Submit complete documentation including ICD-10 codes, prior therapy failures, and recent labs, (3) Use Cigna's provider portal or fax for 72-hour standard review. If denied, you have 180 days for internal appeals and 60 days for external review through Ohio Department of Insurance. Start today by confirming REMS enrollment—this is the #1 denial reason.

Table of Contents

What This Guide Covers

This comprehensive guide helps Ohio residents get Revlimid (lenalidomide) covered by Cigna insurance. Whether you're newly diagnosed with multiple myeloma, myelodysplastic syndrome, or mantle cell lymphoma, we'll walk you through every step of the prior authorization process and show you how to appeal if initially denied.

Who this helps:

  • Patients prescribed Revlimid by their oncologist
  • Caregivers managing insurance approvals
  • Clinicians submitting prior authorizations
  • Anyone facing a Cigna denial for lenalidomide

Before You Start: Coverage Verification

Step 1: Confirm Your Plan Type

Call the member services number on your Cigna insurance card to verify:

  • Whether you have a fully-insured plan (subject to Ohio insurance laws) or a self-funded employer plan (governed by federal ERISA)
  • Your prescription drug formulary tier for Revlimid
  • Whether prior authorization is required (it typically is)

Step 2: Check Formulary Status

Revlimid is typically placed in Tier 4-5 (specialty) with restrictions. Log into your Cigna member portal or call to confirm:

  • Current formulary tier
  • Any quantity limits
  • Step therapy requirements
  • Preferred specialty pharmacy (usually Accredo)

Step 3: Verify REMS Compliance

This is critical: Both your prescriber and dispensing pharmacy must be enrolled in the FDA's Lenalidomide REMS program before any authorization can proceed. Verify enrollment at bmsremspatientsafety.com or have your clinic confirm registration status.

Gather Required Documentation

Essential Documents Checklist

Medical Information:

  • Primary diagnosis with ICD-10 code (e.g., C90.0 for multiple myeloma)
  • Complete pathology report confirming diagnosis
  • Recent lab results (CBC, comprehensive metabolic panel) within 14-30 days
  • Current imaging showing disease status
  • Detailed prior therapy history with dates, doses, and outcomes

Clinical Requirements:

  • Documentation of prior treatment failures or intolerances
  • Current performance status assessment
  • Renal function tests (creatinine clearance for dosing)
  • For women of childbearing potential: negative pregnancy test results

Insurance Documents:

  • Current insurance card with member ID
  • Any previous denial letters
  • Explanation of Benefits (EOB) if applicable

Submit Your Prior Authorization Request

Coverage Criteria by Diagnosis

Indication Required Criteria Documentation Needed
Multiple Myeloma Age ≥18; used with dexamethasone; prior therapy documented ICD-10 C90.0; prior regimen failures; current disease status
Mantle Cell Lymphoma Age ≥18; used with rituximab OR ≥1 prior regimen failure ICD-10 C83.1; treatment history; progression evidence
MDS with 5q- deletion Cytogenetics confirming deletion; transfusion dependence Bone marrow biopsy; transfusion records; cytogenetic report

Submission Methods

Provider Portal: Most efficient method with real-time status updates

  • Log into Cigna provider portal
  • Complete prior authorization form
  • Upload all supporting documents
  • Submit electronically

Fax Submission:

  • Complete Cigna's prior authorization form
  • Fax to number provided on member's insurance card
  • Include cover sheet with member ID and prescriber information
  • Keep fax confirmation receipt
Tip: Submit complete documentation upfront. Incomplete requests restart the 72-hour review clock and delay approval.

Follow-Up and Timeline Expectations

Standard Timeline

  • Prior authorization review: Up to 72 hours from complete submission
  • Expedited review: 24 hours for urgent cases (requires physician attestation of medical urgency)
  • Medication delivery: 5-7 days after approval through Accredo specialty pharmacy

When to Follow Up

Call Cigna if you haven't received a decision within:

  • 3 business days for standard requests
  • 1 business day for expedited requests

Sample Follow-Up Script: "Hello, I'm calling to check the status of a prior authorization request for Revlimid submitted on [date]. The member ID is [number] and the reference number is [if available]. Can you provide an update on the review status and expected decision date?"

If You Need More Information

Cigna may request additional clinical information. Common requests include:

  • Updated lab values showing adequate blood counts
  • Detailed notes from recent oncology visits
  • Imaging studies demonstrating disease progression
  • Documentation of specific prior therapy failures

Respond promptly to these requests—delays can result in treatment interruptions. Your oncologist's office should coordinate these submissions.

If Your Request is Denied

Don't panic. Many initial denials are overturned on appeal, especially for complex cancer treatments like Revlimid. Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific policies.

First Steps After Denial

  1. Read the denial letter carefully to understand the specific reason
  2. Request a peer-to-peer review if offered
  3. Gather additional evidence addressing the denial reason
  4. File an internal appeal within 180 days

Renewal and Re-Authorization

Revlimid approvals are typically granted for 6-12 months. Calendar reminders for renewal 30-45 days before expiration to avoid treatment gaps.

Renewal Documentation

  • Updated labs and imaging
  • Treatment response assessment
  • Any changes in clinical status
  • Continued medical necessity justification

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Missing REMS certification Confirm prescriber/pharmacy enrollment REMS confirmation numbers
Inadequate lab values Submit recent CBC showing adequate counts Labs within 14 days showing ANC ≥500, platelets ≥30,000
Unmet step therapy Document prior therapy failures Detailed treatment history with dates and outcomes
Off-label use Provide clinical evidence Peer-reviewed studies, NCCN guidelines
Quantity limits exceeded Justify higher dose Weight-based calculations, BSA requirements

Appeals Process in Ohio

Internal Appeals with Cigna

  • Timeline: 180 days from denial date to file
  • Address: Cigna Healthcare, Attn: Appeals, PO Box 188081, Chattanooga, TN 37422
  • Decision timeframe: 30 calendar days for standard appeals
  • Expedited appeals: 72 hours if delay poses serious health risk

External Review Through Ohio Department of Insurance

After exhausting Cigna's internal appeals:

  • Timeline: 60 days after final Cigna denial
  • Contact: Ohio Department of Insurance, 1-800-686-1526
  • Review period: 30 days standard, 72 hours expedited
  • Cost: Free to consumers (insurer pays fees)
  • Decision: Binding on Cigna if approved

The Ohio Department of Insurance provides robust consumer protections, including the ability to independently determine external review eligibility even if Cigna initially claims you're not eligible.

Cost Savings and Support Programs

Manufacturer Support

Bristol Myers Squibb offers patient assistance through:

  • BMS Access Support: Financial assistance and copay support programs
  • Patient Assistance Program: Free medication for eligible uninsured/underinsured patients
  • Copay cards: May reduce out-of-pocket costs for commercially insured patients

Foundation Support

  • Leukemia & Lymphoma Society: Patient aid program
  • CancerCare: Financial assistance for treatment-related expenses
  • Patient Advocate Foundation: Copay relief program

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Revlimid in Ohio? A: Standard review takes up to 72 hours from complete submission. Expedited reviews for urgent cases are completed within 24 hours.

Q: What if Revlimid is non-formulary on my Cigna plan? A: You can request a formulary exception by demonstrating medical necessity and providing clinical rationale for why formulary alternatives aren't appropriate.

Q: Can I request an expedited appeal if denied? A: Yes, if your physician certifies that delay would seriously jeopardize your health, you can request expedited internal appeal (72 hours) and expedited external review (72 hours) in Ohio.

Q: Does step therapy apply if I've tried treatments outside Ohio? A: Yes, prior therapy documentation from any location counts toward step therapy requirements. Ensure your Ohio oncologist has complete treatment records.

Q: What's the success rate for appeals in Ohio? A: While specific Cigna data isn't publicly available, external reviews in Ohio have meaningful success rates, especially when proper clinical evidence and guidelines are provided.

Q: Do I need to use Cigna's specialty pharmacy? A: Typically yes. Cigna usually requires Revlimid to be dispensed through Accredo specialty pharmacy, which is equipped to handle REMS requirements.

From our advocates: We've seen cases where patients initially denied for "inadequate lab values" were approved within days after their oncologist submitted updated CBC results showing recovery from a recent infection. The key was having the clinic proactively monitor and resubmit rather than waiting for the next scheduled appointment. While every case is unique, staying engaged in the process often makes the difference.

Counterforce Health specializes in helping patients, clinicians, and specialty pharmacies navigate complex prior authorization challenges. Our platform analyzes denial letters and plan policies to create targeted appeals that address specific payer requirements, significantly improving approval rates for essential medications like Revlimid.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance company directly for coverage determinations. Coverage policies can change, so verify current requirements with Cigna and consult the Ohio Department of Insurance for the most up-to-date appeals information.

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