The Complete Requirements Checklist to Get Revlimid (lenalidomide) Covered by Aetna (CVS Health) in Texas
Answer Box: Quick Path to Approval
To get Revlimid (lenalidomide) covered by Aetna (CVS Health) in Texas: Submit prior authorization with complete REMS enrollment proof, medical necessity letter documenting failed prior therapies (with specific dates/outcomes), current labs, and NCCN guideline citations. Use Aetna's provider portal for fastest processing (2-5 business days). If denied, appeal internally within 180 days, then request Texas Department of Insurance external review if needed. Start today: Verify REMS enrollment status and gather treatment history documentation.
Table of Contents
- Who Should Use This Checklist
- Member & Plan Basics
- Clinical Criteria Requirements
- Coding & Documentation Hygiene
- Your Documentation Packet
- Submission Process
- Specialty Pharmacy Routing
- After Submission: What to Track
- Five Common Pitfalls to Avoid
- Appeals Process in Texas
- Printable One-Page Checklist
Who Should Use This Checklist
This checklist applies if you're a Texas resident with Aetna (CVS Health) coverage seeking approval for Revlimid (lenalidomide) for FDA-approved indications including:
- Multiple myeloma (newly diagnosed or relapsed/refractory)
- Myelodysplastic syndromes with deletion 5q
- Mantle cell lymphoma (relapsed/refractory)
- Follicular or marginal zone lymphoma
Expected outcome: Following this checklist increases your approval odds significantly. Aetna's denial rate for specialty drugs averages around 22%, but complete documentation with proper REMS compliance typically results in approval within 15-45 days.
Member & Plan Basics
✓ Verify Active Coverage
- Confirm Aetna (CVS Health) coverage is active
- Check member ID matches prescription
- Verify plan type (commercial, Medicare Advantage, Medicaid)
- Call member services: 1-888-632-3862 (commercial) or 1-800-624-0756 (Medicare)
✓ Plan Requirements Check
| Requirement | What to Verify | Where to Find |
|---|---|---|
| Prior Authorization | Required for all Revlimid | Aetna Precertification List |
| Formulary Tier | Check tier status/copay | Member portal or drug guide |
| Deductible | Medical vs. pharmacy benefit | EOB or member services |
| Quantity Limits | 21-28 capsules per 28 days | Plan documents |
Clinical Criteria Requirements
✓ FDA-Approved Indication
Required: Confirmed diagnosis matching FDA labeling:
Multiple Myeloma:
- Newly diagnosed (with dexamethasone)
- Maintenance post-autologous transplant
- ICD-10: C90.00, C90.01, or C90.02
Myelodysplastic Syndromes:
- Deletion 5q cytogenetic abnormality
- Transfusion-dependent anemia
- ICD-10: D46.C
Mantle Cell Lymphoma:
- Relapsed/refractory after ≥2 prior therapies
- One prior therapy must include bortezomib
- ICD-10: C83.1*
✓ Step Therapy Documentation
Critical: Document specific prior treatment failures with dates, doses, and outcomes:
- Bortezomib-based regimen (if multiple myeloma)
- Start/stop dates: ___________
- Dose/schedule: ___________
- Outcome (progression, toxicity): ___________
- Alternative IMiD (if applicable)
- Agent tried: ___________
- Duration: ___________
- Reason for discontinuation: ___________
Note: Vague statements like "failed prior therapy" lead to automatic denials. Include specific progression dates per IMWG criteria or documented toxicities.
✓ Current Clinical Status
Required within 30 days:
- CBC with differential
- Comprehensive metabolic panel (creatinine for dosing)
- Disease-specific markers (M-protein, free light chains for MM)
- Pregnancy test (women of childbearing potential)
Coding & Documentation Hygiene
✓ Diagnosis Coding
| Condition | Primary ICD-10 | Additional Codes |
|---|---|---|
| Multiple Myeloma | C90.00-C90.02 | Stage, complications |
| MDS with del(5q) | D46.C | Transfusion dependency |
| Mantle Cell Lymphoma | C83.1* | Relapsed/refractory status |
✓ HCPCS/NDC Information
- NDC: 59572-405-21 (5mg), 59572-410-21 (10mg), 59572-415-21 (15mg), 59572-420-21 (25mg)
- No J-code (oral medication)
- Units: Days supply (21-28 capsules per cycle)
Your Documentation Packet
✓ Medical Necessity Letter Components
Header Information:
- Patient demographics (name, DOB, member ID)
- Provider NPI, license, specialty
- Date of request
Clinical Justification:
- Confirmed diagnosis with pathology/cytogenetics
- Disease stage/risk stratification
- Prior therapy history (specific agents, dates, outcomes)
- Current disease status (labs, imaging)
- Treatment plan (dose, schedule, monitoring)
- NCCN guideline citation (specific version/page)
- FDA indication reference
✓ Required Attachments
- REMS enrollment confirmation (patient, prescriber, pharmacy)
- Pathology report
- Treatment summary with dates/outcomes
- Current labs (<30 days)
- NCCN guideline printout (relevant pages)
Clinician Corner: Counterforce Health can help generate evidence-backed medical necessity letters that align with Aetna's specific coverage criteria, potentially reducing approval time and appeal risk.
Submission Process
✓ Correct Form & Portal
- Use Aetna provider portal for fastest processing
- Alternative: Fax precertification form (verify current fax with member services)
- Request expedited review if urgent (hospitalized, life-threatening delay)
✓ Required Fields That Cause Rejections
- Complete member information (ID, group number, plan type)
- Prescriber NPI and DEA (if controlled substance)
- REMS certification numbers (all parties)
- Specific ICD-10 codes (not just "cancer" or "blood disorder")
- Exact medication strength and NDC
- Start date and duration of therapy
✓ Timeline Expectations
| Review Type | Decision Time | When to Use |
|---|---|---|
| Standard | 15-45 days | Stable disease, planned treatment |
| Expedited | 72 hours | Urgent medical need, hospitalized |
Specialty Pharmacy Routing
✓ CVS Specialty Coordination
Once approved, Aetna typically requires CVS Specialty for Revlimid:
- Prescription transferred to CVS Specialty
- REMS verification completed
- Patient enrollment in specialty pharmacy program
- Shipping address confirmed
- Insurance benefits verification
Contact: CVS Specialty customer service for transfer assistance
After Submission: What to Track
✓ Confirmation & Status Monitoring
- Record submission confirmation number: ___________
- Note submission date: ___________
- Set calendar reminder to check status in 5-7 business days
- Document any additional information requests
- Save all correspondence for potential appeals
✓ Status Check Schedule
- Day 7: Call to confirm receipt and completeness
- Day 14: Request status update if standard review
- Day 30: Escalate if no decision received
- Day 45: Consider filing complaint with Texas Department of Insurance
Five Common Pitfalls to Avoid
| Pitfall | Why It Causes Denial | How to Fix |
|---|---|---|
| Incomplete REMS | FDA requirement; auto-denial | Verify all parties enrolled with confirmation numbers |
| Vague prior therapy | Can't assess step therapy | Include specific dates, doses, outcomes, progression criteria |
| Outdated labs | Safety/dosing concerns | Ensure all labs <30 days old at submission |
| Missing guidelines | No medical necessity support | Include NCCN version/page, FDA indication reference |
| Wrong submission route | Processing delays | Use provider portal; verify current fax if needed |
From our advocates: One patient's initial denial for "incomplete documentation" was overturned within 48 hours after resubmitting with specific REMS confirmation numbers and dated treatment failure documentation. The key was replacing "tried and failed multiple agents" with exact regimens, dates, and IMWG progression criteria. This approach works consistently when documentation gaps are properly addressed.
Appeals Process in Texas
✓ Internal Appeal (First Level)
Timeline: File within 180 days of denial Process:
- Submit appeal letter addressing specific denial reasons
- Include additional evidence (updated labs, peer-reviewed studies)
- Request specialist-to-specialist review (hematologist/oncologist)
- Decision within 30 days (expedited: 72 hours if urgent)
✓ External Review (Texas Department of Insurance)
If internal appeal denied on medical necessity grounds:
Timeline: File within 4 months of final internal denial Process:
- Aetna provides IRO request form with denial notice
- Submit to Texas Department of Insurance
- Independent medical review by specialist
- Decision binding on Aetna (20 days standard, 5 days urgent)
- Free to patient; Aetna pays IRO costs
Contact: TDI Consumer Help: 1-800-252-3439
Note: Self-funded employer plans follow federal ERISA appeals, not Texas IRO process. Check your plan documents or contact HR to confirm.
Printable One-Page Checklist
Before Submission: □ REMS enrollment confirmed (patient, prescriber, pharmacy) □ Medical necessity letter with specific prior therapy failures □ Current labs (<30 days): CBC, CMP, disease markers □ Correct ICD-10 codes and NDC numbers □ NCCN guideline citation included
Submission: □ Use Aetna provider portal or verified fax □ Request expedited if urgent medical need □ Record confirmation number and date □ Set follow-up reminders (7, 14, 30 days)
If Denied: □ Review specific denial reasons □ File internal appeal within 180 days □ Request specialist peer review □ Consider Texas IRO external review if medical necessity dispute □ Contact Counterforce Health for appeal assistance
Key Contacts:
- Aetna Member Services: 1-888-632-3862 (commercial), 1-800-624-0756 (Medicare)
- Texas Department of Insurance: 1-800-252-3439
- CVS Specialty: Transfer assistance via customer service
Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance.
For additional help with complex denials or appeals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals using payer-specific workflows and clinical documentation requirements.
Sources & Further Reading
- Aetna Precertification List 2024 (PDF)
- Aetna Lenalidomide Coverage Policy
- Texas Department of Insurance Consumer Complaints
- BMS REMS Patient Safety Portal
- Revlimid Reimbursement and Coding Guide (PDF)
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