By Counterforce Health Team in Revlimid (lenalidomide) —

How to Get Revlimid (Lenalidomide) Covered by Humana in Pennsylvania: Appeals Guide, Forms, and Coding Requirements

Answer Box: Revlimid Coverage with Humana in Pennsylvania

Revlimid (lenalidomide) requires prior authorization from Humana in Pennsylvania. The fastest path to approval involves three key steps: (1) Ensure REMS certification for both prescriber and pharmacy, (2) Submit Humana's prior authorization form with complete clinical documentation including ICD-10 codes and treatment history, and (3) If denied, file an internal appeal within 65 days. Since Humana Medicare Advantage follows federal appeals (not Pennsylvania's state external review), use Humana's redetermination process rather than the Pennsylvania Insurance Department. Start today by checking your prescriber's REMS certification status and gathering clinical documentation.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. ICD-10 Codes and Clinical Documentation
  4. REMS Certification Requirements
  5. Common Denial Reasons and Solutions
  6. Appeals Process for Humana in Pennsylvania
  7. Cost-Saving Options
  8. Frequently Asked Questions
  9. Sources and Further Reading

Coverage Requirements at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all Revlimid/lenalidomide prescriptions Humana Prior Authorization Portal
REMS Certification Both prescriber and pharmacy must be certified BMS REMS Patient Safety Portal
Generic Preference Generic lenalidomide preferred over brand Revlimid Humana formulary documents
Appeals Deadline 65 days from denial for Medicare Advantage Humana denial letter
Clinical Documentation ICD-10 codes, treatment history, medical necessity Provider medical records

Step-by-Step: Fastest Path to Approval

1. Verify REMS Certification (Prescriber & Pharmacy)

Who does it: Prescriber and dispensing pharmacy
Timeline: Complete before prescribing
Action: Both must enroll in the Lenalidomide REMS program and obtain certification. Each prescription requires a unique authorization confirmation number from the REMS portal.

2. Check Formulary Status

Who does it: Patient or clinic staff
Timeline: Before submission
Action: Verify current formulary placement through Humana's drug list search tool. Generic lenalidomide is preferred; brand Revlimid may require additional justification.

3. Gather Clinical Documentation

Who does it: Clinical team
Timeline: 1-2 business days
Required documents:

  • Pathology report confirming diagnosis
  • Complete treatment history with response/failure documentation
  • Current labs and imaging
  • ICD-10 codes (see section below)

4. Submit Prior Authorization Request

Who does it: Prescriber or authorized staff
Timeline: Submit 3-5 business days before needed
Methods:

  • Online: Humana provider portal
  • Fax: 877-486-2621
  • Phone: 800-555-CLIN (2546)

5. Include REMS Authorization Number

Who does it: Prescriber
Timeline: With each prescription
Action: Generate confirmation number through REMS portal for pharmacy verification before dispensing.

6. Monitor Decision Timeline

Who does it: Patient or clinic
Timeline: Humana responds within 7 days (standard) or 72 hours (expedited)
Action: Track status through Humana member portal or provider system.

7. Appeal if Denied

Who does it: Patient, prescriber, or authorized representative
Timeline: Within 65 days of denial
Action: File redetermination request with additional clinical evidence through Humana's appeals process.

ICD-10 Codes and Clinical Documentation

Primary Diagnosis Codes for Revlimid Coverage

Multiple Myeloma:

  • C90.00: Multiple myeloma not having achieved remission
  • C90.01: Multiple myeloma in remission
  • C90.02: Multiple myeloma in relapse

Myelodysplastic Syndrome with del(5q):

  • D46.4: Refractory anemia with excess of blasts, unspecified (commonly used for MDS del(5q))
  • Include cytogenetic confirmation of del(5q) abnormality

Mantle Cell Lymphoma:

  • C83.10: Mantle cell lymphoma, unspecified site
  • C83.11-C83.19: Site-specific codes as applicable

Follicular Lymphoma:

  • C82.00-C82.09: Grade I follicular lymphoma (site-specific)
  • C82.10-C82.19: Grade II follicular lymphoma (site-specific)

Required Clinical Documentation

Clinician Corner: Medical Necessity Letter Checklist

Your prior authorization request should include:Diagnosis confirmation: Pathology report with specific subtypeTreatment history: Previous therapies tried, duration, and reason for discontinuationClinical rationale: Why lenalidomide is appropriate for this patient's conditionDosing plan: Specific dose, frequency, and cycle lengthMonitoring plan: Lab schedule and safety assessmentsGuideline support: Reference to NCCN, FDA labeling, or other recognized guidelines

For buy-and-bill scenarios, include NDC numbers, J-codes (J9208 for lenalidomide), and administration details.

REMS Certification Requirements

The Lenalidomide REMS program requires strict compliance due to teratogenic risks. Both prescribers and pharmacies must be certified before any lenalidomide can be dispensed.

Prescriber Requirements

  • Complete Lenalidomide REMS Prescriber Enrollment Form
  • Agree to patient counseling on risks and contraception requirements
  • Conduct or review pregnancy tests for women of reproductive potential
  • Re-enroll patients annually in REMS program

Pharmacy Requirements

  • Become REMS-certified through the program portal
  • Verify REMS authorization confirmation number for each prescription
  • Confirm patient enrollment before dispensing
  • Limit to 28-day supplies with no automatic refills

Authorization Process

Each prescription requires a unique confirmation number generated through the REMS portal after completing patient-specific authorization steps. This number must be verified by the pharmacy before dispensing.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
REMS non-compliance Ensure prescriber/pharmacy certification REMS confirmation number
Missing clinical justification Provide detailed treatment history Prior therapy failures, contraindications
Generic not tried first Request medical necessity exception Documented intolerance or failure
Incorrect diagnosis coding Use specific ICD-10 codes Pathology report, staging information
Quantity limits exceeded Justify dosing based on indication Clinical guidelines, FDA labeling

At Counterforce Health, we help patients and clinicians navigate these complex prior authorization requirements by automatically generating targeted appeals that address each payer's specific criteria. Our platform identifies the exact denial reason and creates evidence-backed rebuttals using the right clinical citations and procedural requirements.

Appeals Process for Humana in Pennsylvania

Important Note: Medicare Advantage vs. Commercial Plans

Humana Medicare Advantage plans follow federal Medicare appeals rules, not Pennsylvania's state external review process. If you have a commercial Humana plan, you may be eligible for Pennsylvania's external review after exhausting internal appeals.

Medicare Advantage Appeals (Most Humana Plans)

  1. Level 1 - Redetermination
    • Deadline: 65 days from denial
    • Timeline: 7 days standard, 72 hours expedited
    • Submit via: Humana member portal, phone, or mail
  2. Level 2 - Independent Review Entity (IRE)
    • Deadline: 60 days from Level 1 denial
    • Timeline: 30 days for decision
    • Process: Automatic referral to independent reviewer

Required Appeal Documentation

  • Copy of original denial letter
  • Additional clinical evidence supporting medical necessity
  • Updated treatment notes or lab results
  • Peer-reviewed literature supporting off-label use (if applicable)
From Our Advocates: We've seen many Revlimid appeals succeed when prescribers include specific details about why alternative treatments aren't suitable—for example, documenting kidney function issues that contraindicate other therapies, or prior severe reactions to preferred agents. The key is connecting your patient's specific clinical situation to the payer's own coverage criteria.

Cost-Saving Options

Manufacturer Support

Bristol Myers Squibb offers several patient assistance programs:

  • Access Support Program: Provides prior authorization assistance and appeals support
  • Patient Assistance Program: Free medication for eligible uninsured/underinsured patients
  • Co-pay Support: Reduces out-of-pocket costs for commercially insured patients

Additional Resources

  • CancerCare Co-Payment Assistance Foundation: Grants for treatment-related costs
  • HealthWell Foundation: Financial assistance for eligible patients
  • Patient Access Network Foundation: Copay assistance for specific conditions

For more information on navigating these programs alongside insurance appeals, Counterforce Health helps coordinate manufacturer support with payer approvals to minimize treatment delays.

Frequently Asked Questions

Q: How long does Humana prior authorization take for Revlimid in Pennsylvania? A: Standard requests receive decisions within 7 calendar days. Expedited requests (for urgent medical situations) are decided within 72 hours.

Q: Can I appeal if Humana requires generic lenalidomide instead of brand Revlimid? A: Yes. You can request a formulary exception by documenting medical necessity for the brand, such as documented intolerance to generic formulations or previous treatment failure.

Q: Does Pennsylvania's external review process apply to Humana Medicare Advantage? A: No. Medicare Advantage plans follow federal appeals rules. Pennsylvania's external review only applies to commercial and marketplace plans.

Q: What if my prescriber isn't REMS-certified? A: Lenalidomide cannot be prescribed without REMS certification. Your prescriber must complete the certification process through the BMS REMS portal before submitting any prescription.

Q: Can I get expedited approval for urgent cases? A: Yes. For urgent medical situations, request expedited prior authorization. Humana must respond within 72 hours for expedited requests.

Q: What happens if I'm already taking Revlimid and Humana denies coverage? A: You can request a transition fill (temporary supply) while appealing the denial. Contact Humana member services immediately to request transition coverage.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for the most current coverage information. For additional help with complex appeals, consider consulting with patient advocacy organizations or legal professionals specializing in healthcare coverage.

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