By Counterforce Health Team in Revlimid (lenalidomide) —

How to Get Revlimid (lenalidomide) Covered by Humana in Washington: Complete Decision Tree and Appeals Guide

Quick Answer: Most Humana Medicare Advantage plans in Washington require prior authorization for Revlimid (lenalidomide) with quantity limits and possible step therapy. Your fastest path to approval: (1) Confirm your diagnosis meets FDA criteria, (2) Have your doctor submit PA documentation to Humana at 1-877-486-2621, and (3) If denied, file an appeal within 65 days or request external review through Washington's Office of Insurance Commissioner at 1-800-562-6900.

Table of Contents

How to Use This Decision Tree

This guide helps you determine whether you qualify for Revlimid (lenalidomide) coverage through Humana in Washington state, and exactly what steps to take based on your situation.

Before you start, gather these documents:

  • Your Humana member ID card
  • Complete diagnosis and ICD-10 codes from your oncologist
  • Lab results (CBC with differential, especially ANC and platelet counts)
  • Documentation of any prior treatments you've tried
  • Any previous denial letters from Humana

Work through each section in order. The decision tree will guide you to the right path based on your specific circumstances.

Eligibility Triage: Do You Qualify?

Step 1: Confirm Your Diagnosis

Revlimid is FDA-approved for specific conditions. Check if yours qualifies:

✓ Likely Eligible:

  • Multiple myeloma (any line of therapy)
  • Myelodysplastic syndromes (MDS) with deletion 5q abnormality
  • Mantle cell lymphoma (relapsed/refractory after prior therapy)

? Possibly Eligible:

  • Other blood cancers where your oncologist believes Revlimid is medically necessary
  • Off-label use supported by medical literature

✗ Not Yet Eligible:

  • No confirmed cancer diagnosis
  • Diagnosis doesn't align with FDA labeling or medical compendia

Step 2: Check Required Lab Values

Revlimid requires routine lab monitoring due to risk of blood count drops:

Required baseline labs:

  • Complete blood count (CBC) with differential
  • Absolute neutrophil count (ANC) > 1,000/µL
  • Platelet count > 50,000/µL

Step 3: REMS Program Compliance

All patients must enroll in the FDA-mandated Lenalidomide REMS program before receiving Revlimid. This includes:

  • Prescriber certification and training
  • Patient enrollment and safety surveys
  • Pregnancy testing (if applicable)
  • Using only REMS-certified pharmacies

If You're "Likely Eligible": Document Checklist

Your doctor needs to submit a prior authorization request to Humana at 1-877-486-2621. Here's what must be included:

Medical Necessity Documentation

  • Diagnosis confirmation: ICD-10 code and staging information
  • Prior treatment history: What you've tried and why it failed or caused intolerance
  • Current disease status: Progression, symptoms, or inadequate response to current therapy
  • Treatment plan: Planned duration, dosing, and monitoring schedule

Required Lab Results

  • Baseline CBC with differential (within 30 days)
  • Kidney and liver function tests
  • Pregnancy test results (if applicable)

REMS Compliance Proof

  • Confirmation of prescriber REMS enrollment
  • Patient REMS enrollment documentation
  • Signed patient-physician agreement forms
Tip: Ask your oncologist's office to submit the PA request electronically through Humana's provider portal for faster processing. Standard decisions take up to 7 days, but expedited requests (for urgent medical need) get decided within 72 hours.

If You're "Possibly Eligible": Tests to Request

If your diagnosis is outside typical FDA indications, you'll need stronger documentation:

Additional Clinical Evidence Needed

  1. Genetic testing results showing specific mutations that respond to Revlimid
  2. Imaging studies demonstrating disease progression on current therapy
  3. Literature review from your oncologist citing peer-reviewed studies supporting off-label use
  4. Tumor board recommendation if available at your treatment center

Timeline for Reapplication

  • Gather additional evidence: 2-4 weeks
  • Resubmit PA request with comprehensive documentation
  • If denied again, proceed directly to appeals process

If "Not Yet Eligible": Alternatives and Exceptions

Similar Medications to Discuss

  • Pomalyst (pomalidomide): Another IMiD with different coverage criteria
  • Thalomid (thalidomide): Older IMiD with broader coverage
  • Proteasome inhibitors: Velcade, Kyprolis, Ninlaro
  • Monoclonal antibodies: Daratumumab, elotuzumab

Formulary Exception Process

Even if Revlimid isn't on your plan's formulary, you can request a formulary exception through Humana. Your doctor must demonstrate:

  • Medical necessity for Revlimid specifically
  • Why formulary alternatives aren't appropriate
  • Clinical evidence supporting the request

Humana typically decides formulary exceptions within 72 hours of receiving complete documentation.

If Denied: Washington Appeals Path

Washington state provides strong consumer protections for insurance appeals. Here's your step-by-step path:

Level 1: Internal Appeal with Humana

Timeline: File within 65 days of denial notice Decision time: 7 days standard, 72 hours expedited How to file:

  • Phone: Number on your Humana member ID card
  • Mail: Humana Grievances and Appeals, P.O. Box 14546, Lexington, KY 40512-4546
  • Online: Through your Humana member portal

Required documents:

  • Copy of denial letter
  • Additional medical records supporting medical necessity
  • Prescriber letter explaining why Revlimid is essential
  • Any new lab results or imaging

Level 2: External Review (IRO)

If Humana upholds the denial, Washington law gives you the right to independent external review.

Timeline: Request within 4 months of final internal denial Decision time: 15-20 days standard, 72 hours expedited How to file: Through Washington's Office of Insurance Commissioner

What happens: An independent medical expert reviews your case and can override Humana's denial. If the IRO approves coverage, Humana must comply.

From our advocates: "We've seen many Washington patients successfully overturn Revlimid denials through external review, especially when the prescribing oncologist provides detailed letters explaining why alternative treatments aren't suitable. The key is submitting comprehensive medical records within the five-day window after the IRO is assigned."

Coverage Requirements at a Glance

Requirement Revlimid (lenalidomide) Where to Find It Source
Prior Authorization Required for most Humana plans Plan formulary or member portal Humana Drug List
Quantity Limits Common (30-day supply max) Denial letter or formulary GoodRx Coverage Guide
Step Therapy Sometimes required PA determination letter Humana provider portal
REMS Enrollment Mandatory for all patients FDA requirements BMS REMS Program
Lab Monitoring CBC every 2 weeks x 2 months FDA prescribing information Myeloma.org
Appeals Deadline 65 days from denial Medicare regulations CMS Appeals Guide

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Not medically necessary" Submit detailed oncologist letter with clinical rationale and treatment history
"REMS not completed" Ensure all REMS enrollment forms are submitted; contact specialty pharmacy
"Quantity exceeds limits" Request quantity exception with dosing justification from prescriber
"Step therapy required" Document failed prior therapies or contraindications to alternatives
"Off-label use" Provide peer-reviewed literature and medical society guidelines supporting use
"Labs inadequate" Submit recent CBC with differential and other required monitoring labs

FAQ: Revlimid Coverage in Washington

Q: How long does Humana prior authorization take in Washington? A: Standard PA decisions take up to 7 days. Expedited requests (for urgent medical need) are decided within 72 hours. You can track status through your Humana member portal.

Q: What if Revlimid isn't on my Humana formulary? A: You can request a formulary exception. Your doctor must demonstrate medical necessity and why covered alternatives aren't appropriate. Decisions typically come within 72 hours.

Q: Can I get an expedited appeal if my cancer is progressing? A: Yes. Washington allows expedited appeals when waiting could jeopardize your health. Call the number on your Humana member card and specifically request expedited review.

Q: Does Washington's external review cost anything? A: No. External review through Washington's IRO process is free to consumers. The state and your insurer cover the costs.

Q: What happens if I can't afford Revlimid while appealing? A: Contact BMS Access Support for patient assistance programs. Some foundations also provide grants for cancer medications during appeals.

Q: How do I find a REMS-certified pharmacy in Washington? A: Your oncologist's office or specialty pharmacy can help locate certified pharmacies. Many major chains and specialty pharmacies participate in the REMS program.

Counterforce Health helps patients and clinicians navigate complex prior authorization and appeals processes by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed appeals. The platform identifies specific denial reasons and drafts point-by-point rebuttals aligned with each payer's requirements, pulling appropriate medical literature and ensuring all procedural requirements are met. For more information about streamlining your appeals process, visit www.counterforcehealth.org.

When dealing with Humana denials in Washington, having the right documentation and understanding the appeals timeline can make the difference between approval and continued delays. Counterforce Health can help ensure your appeal includes all necessary clinical evidence and meets Humana's specific requirements for Revlimid coverage.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and appeal procedures may change. For personalized assistance with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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