By Counterforce Health Team in Revlimid (lenalidomide) —

How to Get Revlimid (lenalidomide) Covered by Humana in Florida: Complete Approval Guide

Answer Box: Getting Revlimid (lenalidomide) Covered by Humana in Florida

Humana requires prior authorization for lenalidomide (generic Revlimid) in Florida Medicare Advantage plans. The fastest path to approval: (1) Ensure your prescriber is REMS-certified, (2) Submit Humana's PA form with complete clinical documentation including diagnosis, prior therapies, and recent labs, and (3) Use CenterWell Specialty Pharmacy for dispensing. Start today by calling Humana at 800-555-2546 to request the current PA form. If denied, you have 65 days to appeal and can request expedited review for urgent cases.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for lenalidomide (generic only covered) Humana provider portal Humana PA Lists
REMS Compliance Prescriber and patient must be certified FDA/BMS REMS program FDA Label
Specialty Pharmacy Must use CenterWell or approved network CenterWell: 800-486-2668 CenterWell Specialty
Quantity Limits 30-day supply maximum Plan documents Humana Drug Lists
Appeal Deadline 65 days from denial notice CMS regulations Medicare Appeals

Step-by-Step: Fastest Path to Approval

1. Verify REMS Certification

Who: Prescriber
Action: Ensure enrollment in the Revlimid REMS program
Timeline: Complete before prescribing
Source: BMS REMS Program

2. Obtain Prior Authorization Form

Who: Clinic staff or prescriber
Action: Call Humana at 800-555-2546 or download from provider portal
Timeline: Same day
Source: Humana PA Process

3. Gather Required Documentation

Who: Clinic staff
Documents needed:

  • Multiple myeloma diagnosis with ICD-10 code
  • Prior therapy history and outcomes
  • Recent CBC, comprehensive metabolic panel
  • Pathology/bone marrow biopsy results Timeline: 1-2 days

4. Complete PA Submission

Who: Prescriber
Method: Online portal, fax to 877-486-2621, or phone
Timeline: Submit within 24-48 hours of gathering docs
Source: Humana Provider Portal

5. Route to Specialty Pharmacy

Who: Patient or clinic
Action: Transfer prescription to CenterWell Specialty Pharmacy
Contact: 800-486-2668
Timeline: Can be done simultaneously with PA submission

6. Follow Up on Decision

Who: Clinic staff
Timeline: Humana responds within 72 hours (standard) or 24 hours (expedited)
Next steps: If approved, coordinate with specialty pharmacy; if denied, proceed to appeals

A Realistic Revlimid Approval Scenario

Patient Profile: Maria's Multiple Myeloma Journey

Maria, a 67-year-old Florida resident with Humana Medicare Advantage, was diagnosed with multiple myeloma after experiencing fatigue and bone pain. Her oncologist recommended lenalidomide maintenance therapy following her initial treatment response to bortezomib-based induction.

Pre-Authorization Preparation

Clinical Documentation Gathered:

  • Confirmed MM diagnosis (ICD-10: C90.00)
  • Bone marrow biopsy showing plasma cell infiltration
  • Prior therapy: VRd (bortezomib, lenalidomide, dexamethasone) induction with good partial response
  • Recent labs: CBC showing stable counts, creatinine 1.1 mg/dL
  • ECOG performance status 1

REMS Compliance: Maria's oncologist was already REMS-certified. The clinic completed patient enrollment, including contraception counseling documentation (Maria is postmenopausal) and signed patient-physician agreement.

Submission Process

The clinic submitted Humana's PA form via their provider portal, including:

  • Completed prior authorization request
  • Clinical notes detailing treatment history
  • Lab results from the past 30 days
  • REMS certification confirmation
  • Prescription routed to CenterWell Specialty Pharmacy

Initial Outcome: Approval

Humana approved the request within 48 hours. The approval was based on:

  • Clear MM diagnosis meeting FDA-approved indication
  • Appropriate prior therapy documented
  • REMS compliance verified
  • Request aligned with NCCN guidelines

Approval terms: 12-month authorization for lenalidomide 25mg daily, 21 days per 28-day cycle, dispensed in 30-day supplies through CenterWell.

Lessons Learned

What worked well:

  • Complete documentation submitted upfront
  • REMS compliance verified before submission
  • Used Humana's preferred specialty pharmacy network
  • Clear treatment history with objective response data

What we'd do differently:

  • Could have expedited by calling Humana's PA hotline for complex cases
  • Earlier coordination with CenterWell would have reduced patient wait time
From our advocates: In our experience helping patients navigate Revlimid approvals, the most common stumbling block is incomplete prior therapy documentation. We've found that including specific dates, drug names, and objective response measures (like M-protein levels) significantly improves approval rates. This is a composite tip based on multiple cases, not individual patient data.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Missing REMS compliance Submit REMS certification Prescriber and patient enrollment confirmations
Insufficient prior therapy documentation Provide detailed treatment history Specific regimens, dates, response/progression data
Off-label use without justification Submit medical necessity letter NCCN guideline reference, peer-reviewed literature
Inadequate lab monitoring Update with recent results CBC, CMP, LFTs within 30 days
Non-formulary status Request formulary exception Comparative effectiveness statement

Appeals Playbook for Humana in Florida

Internal Appeal (Redetermination)

  • Deadline: 65 days from denial notice
  • How to file: Call 800-555-2546, online portal, or written request
  • Decision timeline: 7 days (standard), 72 hours (expedited)
  • Required: Additional clinical documentation, prescriber statement

Expedited Appeal

  • When to use: Serious jeopardy to health, life, or ability to regain maximum function
  • Timeline: 24-hour decision for coverage determinations
  • How to request: Specify "expedited" in appeal request

External Review (Florida)

  • When available: After exhausting internal appeals
  • Deadline: 4 months after final internal denial
  • How to request: Through Florida Department of Financial Services
  • Contact: Florida DFS at 877-693-5236
  • Cost: Free to consumer

Peer-to-Peer Review

During appeals, request a clinical discussion between your prescriber and Humana's medical director. This isn't guaranteed but can be effective for complex cases requiring clinical nuance.

Clinician Corner: Medical Necessity Letter

Essential Components Checklist

Patient-Specific Clinical Information:

  • Confirmed MM diagnosis with staging
  • Performance status and comorbidities
  • Prior treatment regimens with specific dates
  • Objective response measurements
  • Disease progression documentation

Treatment Rationale:

  • Why lenalidomide is appropriate for this patient
  • Contraindications to alternative therapies
  • Alignment with FDA labeling or NCCN guidelines
  • Expected treatment duration and monitoring plan

Supporting Evidence:

Tip: Humana's medical reviewers respond well to letters that directly address their coverage criteria. Reference specific policy language when possible and avoid generic template language.

Costs & Patient Assistance

Manufacturer Support

  • Bristol Myers Squibb Patient Assistance: BMS Access Support
  • Eligibility: Income-based for uninsured/underinsured patients
  • Coverage: May provide free medication

Copay Assistance

  • Commercial insurance: Up to $25,000 annual benefit
  • Medicare patients: Not eligible for manufacturer copay cards due to federal law

Foundation Support

FAQ

How long does Humana prior authorization take for Revlimid in Florida?
Standard requests receive decisions within 72 hours; expedited requests within 24 hours. Submit complete documentation to avoid delays.

What if lenalidomide isn't on Humana's formulary?
Request a formulary exception with medical necessity justification. Your prescriber must explain why covered alternatives aren't appropriate.

Can I use any pharmacy for Revlimid?
No, Humana requires specialty medications like lenalidomide to be dispensed through CenterWell Specialty Pharmacy or other approved network specialty pharmacies.

Does step therapy apply to Revlimid?
Humana may require documentation of prior therapies, but specific step therapy requirements vary by plan. Check your specific plan documents.

What if I'm traveling and need a refill?
Specialty medications typically require advance planning. Contact CenterWell at least 7-10 days before travel to arrange delivery or temporary supply.

How often do I need reauthorization?
Most approvals are valid for 12 months. Your prescriber will need to submit renewal documentation showing continued medical necessity and disease stability.

When to Escalate

Contact Florida Department of Financial Services if:

  • Humana violates appeal timelines
  • You're unable to access the appeals process
  • You believe Humana isn't following their own policies

Florida Insurance Consumer Helpline: 877-693-5236
Online complaints: MyFloridaCFO.com

Required documentation for complaints:

  • Insurance policy information
  • Denial letters and appeal responses
  • Timeline of communications
  • Clinical documentation supporting medical necessity

At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, plan policies, and clinical notes to create targeted, evidence-backed appeals that address specific payer criteria. By pulling the right citations and weaving them into comprehensive rebuttals, we help streamline the approval process for complex medications like lenalidomide.

Whether you're dealing with prior authorization requirements, formulary exceptions, or appeals processes, having the right documentation and approach makes all the difference. The key is understanding each payer's specific requirements and presenting clinical information in a way that directly addresses their coverage criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific plan and consult healthcare providers for medical decisions. For assistance with insurance concerns in Florida, contact the Department of Financial Services at 877-693-5236.

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