How to Get Revlimid (Lenalidomide) Covered by UnitedHealthcare in Ohio: Complete PA Guide and Appeals Process
Answer Box: Getting Revlimid Covered by UnitedHealthcare in Ohio
UnitedHealthcare requires prior authorization (PA) for Revlimid (lenalidomide) across all indications, with mandatory REMS enrollment and specific clinical criteria. In Ohio, you have strong appeal rights through two internal levels plus external review via the Ohio Department of Insurance within 180 days of final denial.
Fastest path to approval:
- Verify REMS certification (prescriber and pharmacy) via BMS portal
- Submit complete PA with diagnosis codes, prior therapy history, and clinical documentation
- If denied, appeal immediately with medical necessity letter citing specific plan criteria
Start today: Call UnitedHealthcare at 866-889-8054 to confirm PA requirements for your specific plan.
Table of Contents
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- REMS Program Requirements
- Common Denial Reasons & How to Fix Them
- Appeals Process in Ohio
- Medical Necessity Documentation
- Cost Considerations and Support Programs
- When to Escalate to Ohio Regulators
- Frequently Asked Questions
Coverage Requirements at a Glance
| Requirement | What It Means | Where to Find It |
|---|---|---|
| Prior Authorization | Required for all indications | UHC PA Form |
| REMS Enrollment | Mandatory for prescriber, pharmacy, and patient | BMS REMS Portal |
| Formulary Tier | Specialty Tier 3 | OptumRx formulary |
| Quantity Limit | 28-day maximum supply | UHC policy |
| Step Therapy | May apply for new patients (generic preference) | Plan-specific |
| Appeals Deadline | 180 days from final denial for external review | Ohio DOI |
Step-by-Step: Fastest Path to Approval
1. Verify REMS Certification (1-2 weeks before prescribing)
Who: Prescriber and pharmacy Action: Complete certification at BMS Lenalidomide REMS Portal Timeline: Allow 1-2 weeks for new certifications Source: BMS Access Support
2. Gather Required Documentation
Who: Clinical team Documents needed:
- ICD-10 diagnosis codes (C90.00 for multiple myeloma, D46.B for del(5q) MDS)
- Complete blood count and kidney function tests (within 30 days)
- Prior therapy history with dates and outcomes
- Pathology reports confirming diagnosis
3. Submit Prior Authorization
Who: Prescriber How: UHC provider portal (preferred) or fax Timeline: 72-hour standard review; expedited available for urgent cases Phone: 866-889-8054 Form: Revlimid PA Notification
4. Patient REMS Enrollment
Who: Patient Requirements:
- Sign informed consent
- Complete pregnancy testing (if applicable)
- Contraception counseling and documentation
5. Pharmacy Verification
Who: REMS-certified specialty pharmacy Action: Confirm REMS enrollment and dispense 28-day supply Network options: OptumRx Specialty, other UHC-contracted pharmacies
6. Monitor Authorization Status
Who: Patient or clinic staff How: Check UHC provider portal or call member services Timeline: Follow up if no response within 72 hours
7. Appeal if Denied
Who: Patient or prescriber Timeline: File within plan's internal appeal deadline Next step: Ohio external review if internal appeals unsuccessful
REMS Program Requirements
Revlimid is subject to strict Risk Evaluation and Mitigation Strategy (REMS) requirements due to severe birth defects and blood clots. All three parties must be certified before dispensing can occur.
Prescriber Requirements
- Complete REMS certification training
- Obtain prescriber authorization number
- Counsel patients on risks and contraception
- Monitor compliance with pregnancy testing
Patient Requirements
- Sign informed consent acknowledging risks
- Complete baseline pregnancy test (females of reproductive potential)
- Use two forms of contraception or maintain abstinence
- Monthly pregnancy testing during treatment plus 30 days after
Pharmacy Requirements
- REMS certification for dispensing lenalidomide
- Verify patient enrollment before each fill
- Maximum 28-day supply per prescription
- Confirm contraception compliance
Note: REMS non-compliance is the most common reason for Revlimid denials. Ensure all parties complete certification before submitting PA requests.
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn | Required Documentation |
|---|---|---|
| REMS non-compliance | Complete all certifications first | REMS confirmation numbers |
| Missing diagnosis details | Submit specific ICD-10 codes and pathology | Lab reports, staging information |
| Insufficient prior therapy history | Document previous treatments and outcomes | Treatment dates, response assessments |
| Generic preference (step therapy) | Medical necessity letter for brand | Contraindications to generic, stability on brand |
| Quantity limit exceeded | Justify dosing based on indication | FDA labeling, clinical guidelines |
Medical Necessity Letter Template
When appealing a denial, include these key elements:
- Patient demographics and diagnosis with specific ICD-10 codes
- Prior therapy summary including dates, doses, and reasons for discontinuation
- Clinical rationale for Revlimid based on FDA labeling and guidelines
- Contraindications to preferred alternatives if applicable
- Monitoring plan and expected outcomes
Appeals Process in Ohio
Ohio provides robust consumer protections for health insurance appeals, including external review through independent medical experts.
Internal Appeals (Required First Step)
- Timeline: File within plan's specified deadline (typically 60-180 days)
- Levels: Usually 2 internal appeal levels
- How to file: UHC member portal, written request, or phone
- Expedited option: Available if delay would seriously jeopardize health
External Review (After Internal Appeals)
- Deadline: 180 days from final internal denial
- Cost: Free to patient
- Process: Independent Review Organization (IRO) assigned randomly
- Timeline: 30 days for standard review, 72 hours for expedited
- Authority: IRO decision is binding on UnitedHealthcare
Ohio Department of Insurance Contact
- Consumer Hotline: 800-686-1526
- External Review Email: [email protected]
- Technical Assistance: 614-644-0188
Tip: Ohio's external review process has strong consumer protections. Even if UnitedHealthcare claims your case isn't eligible, the Ohio Department of Insurance can independently determine eligibility and order a review.
Medical Necessity Documentation
UnitedHealthcare's PA criteria vary by indication. Here are the key requirements:
Multiple Myeloma
- Confirmed diagnosis with appropriate staging
- Documentation of prior therapies if not first-line
- Combination partner details (e.g., with dexamethasone)
- Renal function assessment for dosing
Myelodysplastic Syndromes (MDS)
- Symptomatic anemia documentation
- del(5q) cytogenetics preferred but not always required
- Transfusion dependence history
- Prior therapy failures if applicable
Follicular and Marginal Zone Lymphoma
- Histologic confirmation of diagnosis
- Documentation of previous treatment
- Plan for rituximab combination therapy
- Staging and response assessments
Cost Considerations and Support Programs
Insurance Coverage
- Tier: Specialty Tier 3 with prior authorization
- Typical copay: $100-500+ per month depending on plan
- Deductible: May apply before copay assistance
Manufacturer Support
- BMS Access Support: 1-800-861-0048
- Services: PA assistance, appeals support, benefits verification
- Website: BMSAccessSupport.com
Patient Assistance Options
- Copay cards available for commercially insured patients
- Foundation grants for eligible patients
- Medicare Part D coverage with $2,000 annual out-of-pocket cap (2025)
When to Escalate to Ohio Regulators
Contact the Ohio Department of Insurance if:
- UnitedHealthcare improperly denies external review eligibility
- Appeal deadlines are not met by the insurer
- You suspect unfair claims practices
- Internal appeals process is not followed correctly
Ohio Department of Insurance Consumer Services Division 50 West Town Street, Suite 300 Columbus, OH 43215 Phone: 800-686-1526
Frequently Asked Questions
How long does UnitedHealthcare prior authorization take in Ohio? Standard PA review takes up to 72 hours. Expedited review is available for urgent cases and typically completed within 24 hours.
What if Revlimid is not on my UnitedHealthcare formulary? Even non-formulary drugs can be covered with prior authorization and medical necessity documentation. Appeal through the standard process.
Can I request an expedited appeal in Ohio? Yes, if a delay would seriously jeopardize your health. Both internal and external appeals can be expedited, with external reviews completed within 72 hours.
Does step therapy apply if I'm stable on Revlimid? Generally no. UnitedHealthcare typically exempts stable patients from new step therapy requirements. Document your current response and lack of disease progression.
What happens if my REMS certification expires? Treatment must stop until recertification is complete. Plan ahead and renew certifications before expiration to avoid interruptions.
How do I know if my prescriber is REMS-certified? Check with your prescriber's office or verify through the BMS REMS portal. Only certified prescribers can prescribe lenalidomide.
Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed submissions. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with each payer's specific requirements, increasing approval rates and reducing administrative burden.
For additional support with UnitedHealthcare appeals in Ohio, consider working with Counterforce Health to develop comprehensive appeal strategies tailored to your specific situation.
Sources & Further Reading
- UnitedHealthcare Revlimid PA Form
- BMS Lenalidomide REMS Program
- Ohio Department of Insurance Appeals Process
- Ohio External Review Information
- BMS Revlimid Reimbursement Guide
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 requirements may change; verify current information with official sources.
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