By Counterforce Health Team in Revlimid (lenalidomide) —

Lowering Out-of-Pocket Costs for Revlimid (Lenalidomide) with UnitedHealthcare in New York: Copay Programs, Appeals, and Financial Assistance

Answer Box: Getting Revlimid Covered Affordably in New York

Revlimid (lenalidomide) costs can be reduced significantly with UnitedHealthcare in New York through manufacturer copay assistance (commercial plans only), foundation grants, and tier exception appeals. Start by checking your formulary tier placement, then apply for Bristol Myers Squibb's copay program at 1-800-861-0048. If denied coverage, use New York's external appeal process through the Department of Financial Services within 4 months. Medicaid/Essential Plan members pay $0 copay when approved.

First step today: Call UnitedHealthcare member services to confirm your plan's Revlimid tier placement and prior authorization requirements.

Table of Contents

  1. What Drives Revlimid Costs with UnitedHealthcare
  2. Investigating Your Benefits
  3. Manufacturer Copay Assistance Programs
  4. Foundation Grants and Financial Aid
  5. Requesting Tier Exceptions
  6. Specialty Pharmacy Coordination
  7. Appeals Process in New York
  8. Annual Renewal Planning
  9. Conversation Scripts
  10. FAQ

What Drives Revlimid Costs with UnitedHealthcare

Understanding your out-of-pocket costs for Revlimid starts with knowing how UnitedHealthcare structures its specialty drug benefits. The key factors that determine what you'll pay include:

Formulary Tier Placement Revlimid typically falls under UnitedHealthcare's specialty tier, which carries higher cost-sharing than standard prescription drugs. Commercial plans may require 20-40% coinsurance, while Medicaid and Essential Plan members in New York pay $0 copay for oral chemotherapy drugs like Revlimid.

Prior Authorization Requirements All UnitedHealthcare plans require prior authorization for Revlimid, processed through OptumRx. This step can delay access but doesn't directly affect your copay once approved.

REMS Program Compliance Revlimid's Risk Evaluation and Mitigation Strategy (REMS) program adds complexity but doesn't increase costs. However, non-compliance can lead to coverage denials, potentially forcing you to pay cash prices exceeding $15,000 per cycle.

Note: New York's Medicaid expansion means that if you qualify for Essential Plan or Medicaid, your Revlimid costs drop to $0 regardless of the drug's high list price.

Investigating Your Benefits

Before exploring cost reduction strategies, gather specific information about your UnitedHealthcare coverage:

Essential Information to Collect:

  • Your exact plan name and member ID
  • Current formulary tier for Revlimid
  • Annual deductible and out-of-pocket maximum
  • Specialty drug coinsurance percentage
  • Whether you've met your deductible this year

Questions to Ask UnitedHealthcare Member Services:

  1. "What tier is Revlimid on my specific plan?"
  2. "What's my coinsurance for specialty tier drugs?"
  3. "Do I need to use OptumRx specialty pharmacy?"
  4. "Can I request a tier exception if costs are too high?"
  5. "What's my remaining deductible and out-of-pocket maximum?"

Information to Record:

  • Representative name and reference number
  • Exact quotes about coverage terms
  • Any mention of step therapy requirements
  • Appeals process specific to your plan type

Contact UnitedHealthcare member services or use their mobile app to access real-time benefit information.

Manufacturer Copay Assistance Programs

Bristol Myers Squibb (which acquired Celgene) offers significant copay reduction for commercially insured patients through their Access Support program.

Coverage at a Glance: BMS Copay Assistance

Requirement Details Eligibility Check
Insurance Type Commercial only (no Medicare/Medicaid) Call 1-800-861-0048
Copay Reduction As low as $0 per prescription Program caps may apply
Application Phone or online enrollment BMS Access Support website
Residency U.S. residents only Required for enrollment

How to Apply:

  1. Call BMS Access Support at 1-800-861-0048
  2. Have your commercial insurance card and prescription ready
  3. Complete enrollment over the phone (typically 10-15 minutes)
  4. Receive copay card via mail or email
  5. Present card to your specialty pharmacy with each fill
Important: Government insurance beneficiaries (Medicare, Medicaid, VA, TRICARE) cannot use manufacturer copay programs due to federal anti-kickback laws, but may qualify for other assistance programs.

From Our Advocates: We've seen patients reduce their Revlimid costs from over $3,000 per month to under $25 using BMS copay assistance. The key is applying before your first fill—retroactive coverage isn't guaranteed, so don't wait until after you've already paid full price.

Foundation Grants and Financial Aid

When manufacturer copay programs aren't available or sufficient, independent foundations provide grants for specialty drug costs:

Major Foundation Options:

  • HealthWell Foundation: Covers multiple myeloma and blood cancer treatments
  • Patient Access Network Foundation: Offers Revlimid-specific assistance
  • Leukemia & Lymphoma Society: Patient aid program for blood cancers
  • CancerCare: Financial assistance and copay help

Eligibility Requirements: Most foundations require income limits (typically 400-500% of federal poverty level), U.S. residency, and active treatment with the covered drug. Some accept patients with any insurance type, including Medicare and Medicaid.

Application Process:

  1. Check foundation websites for current funding availability
  2. Gather financial documentation (tax returns, pay stubs)
  3. Obtain physician attestation of medical necessity
  4. Submit applications early in the calendar year when funding is most available
Tip: Foundation funding operates on a first-come, first-served basis and often runs out by mid-year. Apply to multiple foundations simultaneously to increase your chances.

Requesting Tier Exceptions

If Revlimid's specialty tier placement creates unaffordable costs, you can request a tier exception from UnitedHealthcare.

Step-by-Step: Tier Exception Request

  1. Gather Clinical Documentation
    • Physician letter explaining medical necessity
    • Documentation of failed alternatives (if applicable)
    • Current lab results and treatment response data
  2. Submit Exception Request
    • Use UnitedHealthcare provider portal
    • Include all supporting documentation
    • Request coverage at a lower tier level
  3. Await Determination
    • Standard review: 72 hours for urgent, 14 days for non-urgent
    • Approval grants lower-tier pricing for specified period
  4. Appeal if Denied
    • Submit additional clinical evidence
    • Consider peer-to-peer review request
    • Escalate to external appeal if necessary

Evidence to Include:

  • NCCN guideline citations supporting Revlimid use
  • Documentation of contraindications to preferred alternatives
  • Treatment response data showing effectiveness
  • Quality of life impact statements

Specialty Pharmacy Coordination

UnitedHealthcare typically requires Revlimid dispensing through OptumRx specialty pharmacy or other certified REMS pharmacies.

Cost Optimization Strategies:

  • 90-day supplies: Often reduce per-dose costs compared to 30-day fills
  • Mail delivery: May offer slight cost advantages over retail pickup
  • Coordination with copay programs: Ensure specialty pharmacy accepts your manufacturer copay card

Important Coordination Steps:

  1. Confirm your specialty pharmacy accepts BMS copay assistance
  2. Verify REMS program enrollment before first shipment
  3. Set up automatic refills to avoid treatment gaps
  4. Establish backup pharmacy in case of supply issues
Note: Only REMS-certified pharmacies can dispense Revlimid, so switching to a lower-cost pharmacy isn't typically an option.

Appeals Process in New York

New York offers robust appeal rights when UnitedHealthcare denies Revlimid coverage or places it at an unaffordable tier.

Internal Appeals Timeline

Step Deadline Process Expected Response
Initial Denial — UnitedHealthcare issues denial letter Includes appeal instructions
Internal Appeal 180 days from denial Submit via portal, mail, or fax 15-30 days for decision
Expedited Appeal 180 days from denial For urgent medical needs 72 hours for decision

External Appeals Through New York DFS

If UnitedHealthcare upholds their denial, New York's Department of Financial Services offers external review:

Key Details:

  • Deadline: 4 months after final internal denial
  • Fee: $25 (waived for Medicaid/financial hardship)
  • Timeline: 30 days standard, 72 hours expedited
  • Success Rate: 28-49% of appeals result in overturns or partial reversals

Required Documentation:

Additional Support: Community Health Advocates provides free assistance with New York appeals at 888-614-5400.

Annual Renewal Planning

Revlimid costs can change significantly during annual enrollment periods, making forward planning essential.

What Can Change:

  • Formulary tier placement
  • Prior authorization requirements
  • Specialty pharmacy networks
  • Coinsurance percentages
  • Annual deductibles and out-of-pocket maximums

Renewal Checklist:

  • Review Summary of Benefits and Coverage (SBC) documents
  • Confirm Revlimid remains covered under new plan year
  • Reapply for manufacturer copay assistance (programs reset annually)
  • Update foundation grant applications if needed
  • Schedule provider discussion about treatment continuity
Important: Manufacturer copay assistance programs typically reset each calendar year, requiring re-enrollment even if you're already approved.

For patients facing significant cost increases, consider working with Counterforce Health, which specializes in turning insurance denials into successful appeals through targeted, evidence-backed documentation that aligns with payer-specific requirements.

Conversation Scripts

Calling UnitedHealthcare Member Services

"Hi, I need information about coverage for Revlimid, spelled R-E-V-L-I-M-I-D. Can you tell me what tier it's on for my plan, what my coinsurance would be, and whether prior authorization is required? I also need to know if I must use a specific specialty pharmacy."

Requesting Peer-to-Peer Review (for providers)

"I'm requesting a peer-to-peer review for my patient's Revlimid prior authorization denial. The patient has multiple myeloma with documented progression on standard therapy, and Revlimid aligns with NCCN Category 1 recommendations. When can we schedule this review?"

Pharmacy Cost Discussion

"I have manufacturer copay assistance for Revlimid. Can you confirm this will be applied to my prescription and tell me my expected out-of-pocket cost? If there are any issues processing the copay card, please call me before filling the prescription."

FAQ

How long does UnitedHealthcare prior authorization take for Revlimid in New York? Standard prior authorization decisions are issued within 72 hours for urgent requests and 14 days for non-urgent requests. REMS program compliance can add additional processing time.

What if Revlimid isn't on UnitedHealthcare's formulary? Non-formulary drugs can still be covered through medical exception requests. Submit comprehensive clinical documentation explaining why formulary alternatives aren't appropriate for your specific condition.

Can I get expedited appeals for Revlimid denials? Yes, if delaying treatment would seriously jeopardize your health. Both UnitedHealthcare internal appeals and New York DFS external appeals offer expedited review processes with 72-hour decision timelines.

Does UnitedHealthcare step therapy apply to Revlimid? Step therapy requirements vary by diagnosis and plan type. Multiple myeloma patients may need to document prior therapy failures, while MDS patients often receive first-line approval.

What happens if I lose commercial insurance and switch to Medicare? You'll lose eligibility for manufacturer copay assistance but may qualify for Medicare's Low Income Subsidy (Extra Help) program or foundation grants specifically for Medicare beneficiaries.

Can I appeal Revlimid costs even if coverage is approved? Yes, you can request tier exceptions to reduce your coinsurance percentage. This requires clinical documentation explaining why lower-tier alternatives aren't suitable.

How do I find REMS-certified pharmacies that accept UnitedHealthcare? Contact OptumRx specialty pharmacy directly, or use the BMS REMS pharmacy locator to find certified pharmacies in your area that accept UnitedHealthcare.

What if my appeal is denied by New York DFS? DFS external appeal decisions are final and binding. However, you may have additional options through federal appeals processes if you have Medicare coverage, or through state Fair Hearing processes for Medicaid members.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and doesn't constitute medical or legal advice. Insurance coverage and costs vary by individual plan and circumstances. Always verify current requirements with UnitedHealthcare and consult your healthcare provider about treatment decisions. For personalized assistance with complex coverage issues, consider working with Counterforce Health, which helps patients and providers navigate insurance appeals with evidence-backed documentation tailored to specific payer requirements.

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