By Counterforce Health Team in Revlimid (lenalidomide) —

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

Answer Box: Getting Revlimid Covered by Cigna in Washington

Fast Track to Approval: Cigna requires prior authorization for Revlimid (lenalidomide) with strict REMS program compliance. In Washington, patients have strong appeal rights with an 82% overturn rate for specialty drug denials through external review.

Your first step today: Ensure both your prescriber and you are enrolled in the Revlimid REMS program before submitting any prior authorization request. Without REMS enrollment, Cigna will automatically deny coverage.

If denied: Washington law guarantees external review by an Independent Review Organization (IRO) after internal appeals, with decisions binding on Cigna for fully-insured plans.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Documentation Requirements
  5. Submission Process
  6. Specialty Pharmacy Coordination
  7. After Submission: What to Expect
  8. Appeals Process in Washington
  9. Common Denial Reasons & Solutions
  10. Cost Assistance Options
  11. Frequently Asked Questions

Who Should Use This Guide

This guide helps patients and clinicians navigate Cigna's prior authorization process for Revlimid (lenalidomide) in Washington state. You'll need this if:

  • Your doctor prescribed Revlimid for multiple myeloma, myelodysplastic syndromes (MDS), or certain lymphomas
  • Cigna is your insurance carrier (including Medicare Advantage plans)
  • You're facing a prior authorization requirement or denial
  • You need to understand Washington's appeal rights

Expected outcome: With proper documentation and REMS compliance, most medically appropriate Revlimid requests get approved. If initially denied, Washington's external review process overturns 82% of specialty drug denials.

Member & Plan Basics

Coverage Requirements

  • Prior Authorization: Required for all Revlimid prescriptions under Cigna
  • Formulary Status: Typically Tier 4 (specialty) with prior authorization
  • Plan Types Covered: This guide applies to fully-insured Cigna plans; self-funded employer plans may have different rules
  • Deductible: May apply before coverage begins, depending on your specific plan
Note: Verify your plan type by calling the member services number on your insurance card or checking with your employer's HR department.

REMS Program Requirement

Before any coverage consideration, both prescriber and patient must enroll in the Revlimid REMS program. This FDA-mandated safety program includes:

  • Prescriber certification
  • Patient enrollment and periodic surveys
  • Pregnancy testing requirements (when applicable)
  • 28-day supply limits with no automatic refills

Clinical Criteria Requirements

Cigna covers Revlimid for FDA-approved indications when clinical criteria are met:

Coverage Criteria by Indication

Indication Requirements ICD-10 Codes
Multiple Myeloma Age ≥18; used with dexamethasone or as maintenance post-transplant C90.00, C90.01
MDS with del(5q) Transfusion-dependent anemia; del(5q) cytogenetic abnormality confirmed D46.4
Follicular Lymphoma Previously treated; used with rituximab C82.x
Marginal Zone Lymphoma Previously treated; used with rituximab C88.x

Step Therapy Requirements

For most non-myeloma indications, patients must have tried at least one prior appropriate therapy. Documentation must include:

  • Specific medications tried
  • Duration of treatment
  • Reason for discontinuation (failure, intolerance, contraindication)

Laboratory Requirements

  • Multiple Myeloma: Absolute neutrophil count ≥500 cells/mm³, platelet count ≥30,000/mm³
  • MDS: Confirmation of del(5q) abnormality via cytogenetics or FISH

Documentation Requirements

Medical Necessity Letter Components

Your oncologist must provide a comprehensive letter including:

Patient Information

  • Full name, date of birth, insurance ID
  • Prescriber name, specialty, NPI number

Clinical Documentation

  • Primary diagnosis with appropriate ICD-10 code
  • Disease staging/risk stratification
  • Prior treatment history with dates, responses, and reasons for discontinuation
  • Current clinical status and treatment goals

Regulatory Compliance

  • Confirmation of REMS program enrollment
  • Statement that prescriber is REMS-certified
  • Attestation of medical necessity
Tip: Include lab values, imaging reports, and pathology results as supporting documentation to strengthen your case.

Required Attachments

  • Recent clinic notes (within 30 days)
  • Laboratory results supporting diagnosis
  • Documentation of prior therapy failures
  • REMS enrollment confirmation

Submission Process

Prior Authorization Forms

Use Cigna's current prior authorization form, available through:

  • Cigna Provider Portal (verify current link)
  • Express Scripts (for specialty medications)
  • Your specialty pharmacy

Submission Methods

  • Electronic: Cigna provider portal (preferred)
  • Fax: Check current fax number on the PA form
  • Phone: Peer-to-peer review requests
Important: Incomplete forms are automatically denied. Review all required fields before submission.

Specialty Pharmacy Coordination

Cigna typically routes Revlimid through Accredo Specialty Pharmacy or other network specialty pharmacies.

Transfer Process

  1. Prescriber sends prescription to designated specialty pharmacy
  2. Pharmacy initiates prior authorization if not already completed
  3. REMS verification occurs before dispensing
  4. Patient receives medication via overnight shipping

REMS Verification Steps

  • Prescriber REMS certification confirmed
  • Patient enrollment status verified
  • Pregnancy testing completed (if applicable)
  • 28-day supply limit enforced

After Submission: What to Expect

Timeline

  • Standard Review: 3-5 business days
  • Expedited Review: 24-72 hours (for urgent cases)
  • REMS Delays: Additional 1-2 days for enrollment verification

Status Tracking

  • Check status via Cigna member portal
  • Call member services for updates
  • Specialty pharmacy will notify you of approval/denial

Confirmation Numbers

Keep records of:

  • Prior authorization request number
  • Submission date and method
  • Contact person (if submitted by phone)

Appeals Process in Washington

Washington state provides exceptional protections for patients facing insurance denials.

Internal Appeals

First Level

  • File within 180 days of denial
  • Submit via Cigna member portal or written request
  • Include additional clinical documentation
  • Decision within 30 days (expedited: 72 hours)

Second Level (if available)

  • Request within 60 days of first-level denial
  • Peer-to-peer review available
  • Independent medical reviewer

External Review (IRO)

Washington's external review process has an 82% success rate for specialty drug appeals.

Eligibility

Process

  1. Submit written request to Cigna
  2. Cigna forwards materials to Independent Review Organization
  3. You have 5 business days to submit additional documentation
  4. IRO decision within 30 days (expedited: 72 hours)
  5. Decision is binding on Cigna
Washington Advantage: Contact the OIC Consumer Advocacy line at 1-800-562-6900 for free assistance with appeals.

Common Denial Reasons & Solutions

Denial Reason Solution
REMS non-compliance Ensure both prescriber and patient are REMS-enrolled before resubmission
Missing diagnosis details Include specific ICD-10 code, staging, and pathology reports
Lack of step therapy Document prior treatments with dates, responses, and failure reasons
Brand not medically necessary Provide clinical rationale for brand vs. generic lenalidomide
Prescriber not REMS-certified Prescriber must complete REMS certification before prescribing

Counterforce Health Support

Counterforce Health helps patients and clinicians turn insurance denials into successful appeals by analyzing denial letters, identifying specific coverage criteria, and drafting evidence-backed rebuttals. Their platform streamlines the appeals process by automatically generating targeted responses that address each payer's specific requirements and procedural deadlines.

Cost Assistance Options

Manufacturer Support

  • Bristol Myers Squibb Access Support: Patient assistance programs and copay cards
  • Financial eligibility: Based on income and insurance status
  • Application: Available through prescriber or BMS patient support

Foundation Grants

  • Leukemia & Lymphoma Society
  • Patient Advocate Foundation
  • CancerCare Co-Payment Assistance

State Programs

  • Washington Apple Health (Medicaid) may provide additional coverage
  • Prescription assistance programs through Washington State Department of Health

Frequently Asked Questions

How long does Cigna prior authorization take for Revlimid? Standard review is 3-5 business days. REMS verification may add 1-2 days. Expedited review is available for urgent cases.

What if Revlimid is not on Cigna's formulary? Submit a formulary exception request with clinical rationale. Washington's external review process can override formulary restrictions for medically necessary treatments.

Can I request an expedited appeal in Washington? Yes. If delay would jeopardize your health, request expedited review. Decisions come within 72 hours for both internal and external appeals.

Does step therapy apply if I failed treatments outside Washington? Yes. Document all prior therapies regardless of where treatment occurred. Include medical records from previous providers.

What happens if both internal and external appeals fail? External review decisions are binding on Cigna for fully-insured plans. If unsuccessful, consult with a healthcare attorney about additional options.

How do I know if my plan is fully-insured or self-funded? Check with your employer's HR department or call the Washington OIC at 1-800-562-6900. Self-funded plans may have different appeal rights.

From Our Advocates

We've seen many Revlimid denials overturned in Washington when patients provide comprehensive documentation of their REMS enrollment, prior treatment failures, and clear clinical rationale from their oncologist. The key is addressing each specific denial reason with targeted evidence—something that becomes much easier when you understand both Cigna's criteria and Washington's strong consumer protections.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For personalized assistance with appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

Sources & Further Reading

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