By Counterforce Health Team in Revlimid (lenalidomide) —

How to Get Revlimid (Lenalidomide) Covered by Humana in North Carolina: Forms, Appeals, and Support

Quick Answer: Getting Revlimid (Lenalidomide) Covered by Humana in North Carolina

Eligibility: Humana Medicare Advantage and Part D plans require prior authorization for lenalidomide (generic) and may cover brand-name Revlimid with medical necessity justification.

Fastest approval path: Submit prior authorization through Humana's online portal, by fax (877-486-2621), or phone (800-555-2546). Ensure REMS compliance and include diagnosis details, prior therapy failures, and prescriber attestation.

First step today: Verify your Humana plan covers specialty medications, gather your medical records showing prior treatment attempts, and have your oncologist initiate the prior authorization request with complete documentation.

Table of Contents

  1. Verify Your Humana Plan Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. REMS Program Compliance
  5. Appeals Process: Internal and External
  6. Smart NC External Review for North Carolina
  7. Specialty Pharmacy Support
  8. Financial Assistance Programs
  9. Common Denial Reasons and Solutions
  10. FAQ: Revlimid Coverage with Humana

Verify Your Humana Plan Coverage

Before starting the approval process, confirm your specific Humana plan's coverage for specialty medications like Revlimid (lenalidomide).

Coverage varies by plan type:

  • Medicare Advantage: Most plans cover lenalidomide with prior authorization
  • Medicare Part D: Requires prior authorization for both generic lenalidomide and brand Revlimid
  • Commercial plans: Coverage policies may differ from Medicare requirements
Tip: Call the customer service number on your Humana member ID card to verify your specific plan's formulary status for lenalidomide/Revlimid.

What to ask when you call:

  • Is lenalidomide on my plan's formulary?
  • What tier is it placed on?
  • Are there quantity limits or step therapy requirements?
  • Does my plan require specialty pharmacy dispensing?

Required Forms and Documentation

Prior Authorization Request Form

Humana requires the "Request for Medicare Prescription Drug Coverage Determination" form for prior authorization requests. This form is available in both English and Spanish versions on Humana's website.

Essential documentation to include:

  • Complete prior authorization form
  • Prescriber's medical necessity letter
  • Diagnosis with ICD-10 codes
  • Documentation of prior therapy attempts and outcomes
  • Current lab values and staging information
  • REMS program enrollment confirmation

Medical Necessity Letter Requirements

Your oncologist must provide a detailed letter addressing:

Clinical justification:

  • Specific diagnosis (multiple myeloma, MDS, mantle cell lymphoma, etc.)
  • Disease stage and current status
  • Prior treatment history with outcomes
  • Why lenalidomide is medically necessary
  • Expected treatment duration and monitoring plan

Formulary alternatives addressed:

  • Which covered alternatives were tried
  • Reasons for discontinuation (ineffective, intolerance, contraindications)
  • Why lenalidomide is superior for your specific case
Clinician Corner: Include references to NCCN Guidelines, FDA labeling, or peer-reviewed studies supporting lenalidomide use for the specific indication. Attach relevant lab results, imaging reports, and treatment response documentation.

Submission Portals and Methods

Online Submission (Fastest)

Submit prior authorization requests through Humana's Part D prior authorization portal. Healthcare providers can access this through their provider portal for fastest processing.

Fax Submission

Fax number: 877-486-2621

  • Include completed prior authorization form
  • Attach all supporting documentation
  • Use a cover sheet noting "URGENT - Prior Authorization Request for Lenalidomide"

Phone Submission

Provider line: 800-555-CLIN (2546)

  • Available Monday-Friday, 8 a.m. to 8 p.m. local time
  • Have patient information and clinical details ready
  • Follow up with faxed documentation

For professionally administered drugs: 1-866-488-5995

REMS Program Compliance

Revlimid (lenalidomide) is subject to strict Risk Evaluation and Mitigation Strategy (REMS) requirements due to birth defect risks.

Requirements Before Coverage

Prescriber certification:

  • Must be enrolled in the Lenalidomide REMS program
  • Complete required safety training
  • Provide patient counseling on risks

Pharmacy certification:

  • Prescription must be filled at a REMS-certified pharmacy
  • Pharmacy must obtain confirmation numbers before dispensing

Patient enrollment:

  • Complete REMS program registration
  • Undergo pregnancy testing if applicable
  • Commit to contraception requirements and regular monitoring
Note: Insurance approval means nothing without REMS compliance. Ensure all parties (prescriber, pharmacy, patient) are enrolled before expecting coverage.

Appeals Process: Internal and External

Internal Appeals with Humana

If your prior authorization is denied, you have 65 calendar days from the denial notice to file an internal appeal.

How to appeal:

  1. Use Humana's Appeal, Complaint or Grievance Form
  2. Include copy of denial notice and all supporting documentation
  3. Submit additional medical evidence addressing denial reasons

Submission options:

  • Mail: Humana Grievance and Appeal Department, P.O. Box 14165, Lexington, KY 40512-4165
  • Online: Through your Humana member portal
  • Phone: Number on your member ID card

Decision timeframes:

  • Pre-service decisions: 30 calendar days
  • Post-service decisions: 60 calendar days
  • Expedited appeals: 72 hours for urgent situations

Formulary Exception Appeals

For brand-name Revlimid when generic lenalidomide is preferred, request a formulary exception based on medical necessity.

Required elements:

  • Statement that generic alternatives are ineffective or contraindicated
  • Clinical evidence supporting brand-name necessity
  • Documentation of adverse reactions to generic formulations
  • Prescriber attestation of medical necessity

Smart NC External Review for North Carolina

If Humana denies your internal appeal, North Carolina residents can request an independent external review through the state's Smart NC program.

Smart NC Contact Information

Phone: 1-855-408-1212 (toll-free)
Email: [email protected]
Address: Smart NC Program, NC Department of Insurance, 1201 Mail Service Center, Raleigh, NC 27699-1201

External Review Process

Eligibility requirements:

  • Must have exhausted Humana's internal appeal process
  • Denial must be based on medical necessity or experimental treatment determination
  • Must have a state-regulated insurance plan (most Humana plans qualify)

Timeline:

  • Standard review: Decision within 45 days
  • Expedited review: Decision within 72 hours for urgent cases
  • Ultra-expedited: 24-72 hours for urgent non-formulary drug denials

How to apply:

  1. Complete Smart NC external review request form
  2. Submit all Humana denial and appeal documentation
  3. Include additional medical evidence supporting your case
  4. Smart NC assigns an Independent Review Organization (IRO)
Important: The IRO's decision is binding on Humana. If they approve coverage, Humana must provide it within 3 business days.

Smart NC Advocacy Support

Smart NC provides free assistance beyond just processing external reviews:

  • Help completing external review applications
  • Guidance on gathering medical records
  • Communication facilitation with insurers
  • Access to clinical guidelines and medical literature

When to call Smart NC:

  • Before filing an external review (for guidance)
  • If you need help understanding denial reasons
  • To find supporting medical evidence
  • For assistance with appeal documentation

Specialty Pharmacy Support

CenterWell Specialty Pharmacy

Humana operates CenterWell Specialty Pharmacy for high-cost medications like Revlimid.

Contact information:

  • Phone: 1-800-486-2668 (TTY: 711)
  • Prescription fax: 1-877-405-7940

Services provided:

  • Clinical support and medication management
  • Home delivery coordination
  • Financial assistance program identification
  • Prior authorization support
  • REMS program coordination

Transfer process:

  1. Have your current pharmacy fax prescription to CenterWell
  2. CenterWell contacts you to set up delivery
  3. Clinical pharmacist reviews your case
  4. Coordinates with your oncologist for monitoring

Financial Assistance Programs

Bristol Myers Squibb Access Support

The manufacturer offers comprehensive support for Revlimid patients through BMS Access Support.

Programs available:

  • Co-pay assistance for eligible commercial insurance patients
  • Patient assistance program for uninsured/underinsured patients
  • Prior authorization and appeals support
  • Benefit verification services

Additional Resources

  • Counterforce Health helps patients navigate insurance denials by creating targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, potentially saving months in the approval process.
  • CancerCare Financial Assistance: Grants for treatment-related expenses
  • Patient Advocate Foundation: Co-pay relief and case management
  • Leukemia & Lymphoma Society: Financial assistance for blood cancer patients

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
REMS non-compliance Ensure all parties enrolled REMS confirmation numbers
Missing diagnosis details Provide complete clinical picture Pathology reports, staging
Lack of prior therapy documentation Document treatment history Prior regimen summaries, response data
Step therapy not completed Show medical necessity for first-line use Contraindication documentation
Non-formulary status Request formulary exception Medical necessity letter
Quantity limit exceeded Justify higher dose/longer duration Clinical guidelines, prescriber rationale

FAQ: Revlimid Coverage with Humana

Q: How long does Humana prior authorization take in North Carolina? A: Standard prior authorization decisions are made within 72 hours. Expedited requests for urgent situations receive decisions within 24 hours.

Q: What if Revlimid is not on my Humana formulary? A: You can request a formulary exception based on medical necessity. Your doctor must demonstrate that covered alternatives are inappropriate for your specific case.

Q: Can I request an expedited appeal if my cancer is progressing? A: Yes. If delay would seriously jeopardize your health, request expedited processing. Both Humana and Smart NC offer expedited review options.

Q: Does step therapy apply if I've been stable on Revlimid from another state? A: Continuation of therapy exceptions may apply. Provide documentation of current treatment response and stability to support continued coverage.

Q: What happens if I fill Revlimid without prior authorization? A: You may be responsible for the full cost ($18,000-25,000 per cycle). However, some Humana members in certain states may be eligible for reimbursement if they submit a claim afterward.

Q: How do I find a REMS-certified pharmacy in North Carolina? A: Visit the Bristol Myers Squibb REMS website or contact CenterWell Specialty Pharmacy, which is REMS-certified and works directly with Humana plans.

For patients navigating complex insurance approvals, Counterforce Health specializes in turning denials into successful appeals by analyzing payer policies and creating evidence-based rebuttals. Their expertise in specialty drug coverage can be particularly valuable for expensive medications like Revlimid, where initial denials are common but often overturnable with proper documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and individual circumstances. Always consult with your healthcare provider and insurance plan for specific guidance regarding your situation. For official assistance with insurance appeals in North Carolina, contact Smart NC at 1-855-408-1212.

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