By Counterforce Health Team in Revlimid (lenalidomide) —

The Complete Requirements Checklist to Get Revlimid (lenalidomide) Covered by Cigna in New Jersey

Answer Box: Getting Revlimid (lenalidomide) Covered by Cigna in New Jersey

Fastest path to approval: Submit electronic prior authorization (PA) through CoverMyMeds or EviCore with complete REMS enrollment, diagnosis documentation (ICD-10 codes C90.0 for multiple myeloma, D46.Z for MDS, C83.1 for mantle cell lymphoma), and prior therapy history. If denied, file internal appeal within 180 days, then external review through New Jersey IHCAP within 120 days. First step today: Verify your Cigna plan is fully insured in New Jersey (not self-funded ERISA) by calling 1-800-882-4462.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Documentation Standards
  5. Required Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: Tracking & Follow-up
  9. Appeals Process for New Jersey
  10. Common Pitfalls & How to Avoid Them
  11. Printable Checklist

Who Should Use This Checklist

This comprehensive checklist is designed for patients and clinicians seeking Revlimid (lenalidomide) coverage through Cigna in New Jersey. Use this guide if you're dealing with:

  • Multiple myeloma (newly diagnosed, maintenance post-transplant, or relapsed/refractory)
  • Myelodysplastic syndromes (MDS) with del(5q)
  • Mantle cell lymphoma (relapsed/refractory)
  • Follicular lymphoma or marginal zone lymphoma (with rituximab)

Expected outcome: Following this checklist increases approval likelihood by ensuring compliance with Cigna's CNF-541 policy and New Jersey's appeal protections. Success rates for well-documented oncology appeals through New Jersey's external review program range from 20-50%.

Member & Plan Basics

✓ Verify Active Coverage

  • Confirm current Cigna enrollment and effective dates
  • Check if plan includes Express Scripts pharmacy benefit management
  • Verify specialty drug coverage tier for lenalidomide

✓ Determine Plan Type (Critical for Appeals)

Call Cigna at 1-800-882-4462 to confirm:

  • Fully insured New Jersey plan (eligible for IHCAP external review)
  • Self-funded ERISA plan (federal appeals only)
  • Medicare Advantage/Part D (federal Medicare appeals process)

✓ Authorization Requirements

  • Prior authorization required for all lenalidomide products
  • Specialty pharmacy dispensing through Accredo typically required
  • REMS program enrollment mandatory for prescriber, patient, and pharmacy

Clinical Criteria Requirements

✓ FDA-Approved Indications

Multiple Myeloma:

  • Newly diagnosed (with dexamethasone)
  • Maintenance therapy post-autologous stem cell transplant
  • Relapsed/refractory (after ≥1 prior therapy)

MDS:

  • Transfusion-dependent anemia with del(5q) cytogenetic abnormality
  • Lower-risk disease without symptomatic splenomegaly

Mantle Cell Lymphoma:

  • Relapsed/refractory after ≥1 prior therapy including bortezomib

✓ Step Therapy Documentation

Per Cigna's oncology policy:

  • Document prior regimens tried and outcomes
  • Show failure, intolerance, or contraindication to covered alternatives
  • For lymphomas: document rituximab combination or prior therapy requirement

Coding & Documentation Standards

✓ ICD-10 Diagnosis Codes

Condition Primary Code Specific Codes
Multiple Myeloma C90.0 C90.00 (not in remission), C90.01 (in remission), C90.02 (in relapse)
MDS D46.Z D46.C (with isolated del(5q))
Mantle Cell Lymphoma C83.1 C83.10 (unspecified site), C83.11 (head/neck nodes)

✓ HCPCS/NDC Coding

  • J8512 (lenalidomide injection, 1 mg) for buy-and-bill scenarios
  • NDC numbers for oral capsules dispensed through specialty pharmacy
  • Document exact strength and quantity per treatment cycle

Required Documentation Packet

✓ Clinical Documentation

  • Pathology report confirming diagnosis
  • Cytogenetics/FISH results (especially del(5q) for MDS)
  • Prior treatment summary with dates, agents, responses, and toxicities
  • Current staging and performance status
  • Laboratory results (CBC, comprehensive metabolic panel, pregnancy test if applicable)

✓ REMS Compliance Documentation

  • Prescriber REMS enrollment confirmation number
  • Pharmacy REMS certification (typically Accredo for Cigna)
  • Patient-Physician Agreement Form (PPAF) signed and submitted
  • Pregnancy prevention counseling documentation (females of reproductive potential)

✓ Medical Necessity Letter Components

Your oncologist's letter should include:

  • Specific diagnosis with staging/risk stratification
  • Treatment history and why lenalidomide is appropriate now
  • NCCN guideline alignment (category 1 or 2A preferred)
  • Dosing rationale and treatment duration
  • Contraindications to alternative therapies
  • Urgency statement if treatment delay poses clinical risk

Submission Process

✓ Electronic Prior Authorization (Preferred)

Submit through:

  • CoverMyMeds (Cigna-branded portal)
  • EviCore by Evernorth - Pharmacy Drugs (Express Scripts Coverage)
  • SureScripts ePA within your EHR system

✓ Alternative Submission Methods

If ePA unavailable:

  • Phone: 1-800-882-4462 (verbal PA)
  • Fax: Use current Cigna Medication Prior Authorization Form to 855-840-1678 (verify current fax number)

✓ Required Fields That Prevent Rejections

  • Complete patient demographics and insurance information
  • Exact drug name, strength, quantity, and days supply
  • ICD-10 diagnosis codes with appropriate specificity
  • Prescriber NPI and DEA numbers
  • REMS enrollment confirmation numbers

Specialty Pharmacy Routing

✓ Accredo Specialty Pharmacy Setup

For most Cigna plans:

  • Transfer prescription to Accredo (1-800-237-2767)
  • Verify patient enrollment in Accredo's system
  • Confirm shipping address and delivery preferences
  • Schedule delivery coordination with treatment cycles

✓ Alternative REMS-Certified Pharmacies

If Accredo isn't required:

  • Verify pharmacy's REMS certification at bmsremspatientsafety.com
  • Confirm pharmacy can obtain authorization confirmation numbers
  • Ensure pharmacy accepts Cigna/Express Scripts

After Submission: Tracking & Follow-up

✓ Confirmation & Status Tracking

  • Record submission date/time and confirmation number
  • Standard PA timeline: Decision within 72 hours of complete submission
  • Urgent PA timeline: Decision within 24 hours
  • Auto-approval rule: If Cigna doesn't respond within timeline, request is considered approved

✓ Status Check Schedule

  • Day 1: Confirm receipt and completeness
  • Day 3: Follow up if no decision on standard PA
  • Day 1: Follow up if no decision on urgent PA
  • Weekly: Check status until resolution

Appeals Process for New Jersey

✓ Internal Appeals (Required First Step)

Deadline: 180 days from denial date

Level 1 Appeal:

  • Submit detailed appeal letter addressing denial reasons
  • Include additional clinical documentation
  • Request expedited review if clinically urgent
  • Timeline: Decision within 30 days (72 hours if expedited)

Level 2 Appeal:

  • Request peer-to-peer review with oncology specialist
  • Provide NCCN guideline excerpts and clinical trial data
  • Timeline: Additional 30 days

✓ External Review Through IHCAP

Eligibility: Fully insured New Jersey plans only Deadline: 120 days from final internal denial

Required Documentation:

Submission:

  • Online: Maximus IHCAP portal (preferred)
  • Support: 1-888-393-1062 for assistance
  • Timeline: Decision within 45 days (48 hours if expedited)
Note: IHCAP reviews are conducted by independent clinical experts and have no cost to patients. Decisions are binding on insurers.

Common Pitfalls & How to Avoid Them

Pitfall How to Avoid Prevention Strategy
REMS non-compliance Verify all parties enrolled before submission Check bmsremspatientsafety.com enrollment status
Incomplete prior therapy documentation Document all previous treatments with outcomes Create timeline with dates, agents, responses, toxicities
Wrong ICD-10 specificity Use most specific code available Include remission status (C90.01) and site specificity
Missing NCCN alignment Reference specific guideline categories Quote category 1/2A recommendations in medical necessity letter
Generic vs. brand confusion Clarify medical necessity for Revlimid over generic Document intolerance to specific generic manufacturers if applicable

Printable Checklist

✓ Pre-Submission (Patient/Clinic)

  • Verify Cigna coverage and plan type
  • Confirm REMS enrollment (all parties)
  • Gather pathology, labs, prior treatment records
  • Complete medical necessity letter

✓ Submission

  • Submit via CoverMyMeds or EviCore
  • Include all required documentation
  • Record confirmation number and date
  • Set follow-up reminders

✓ If Denied

  • File internal appeal within 180 days
  • Request peer-to-peer review
  • Prepare for IHCAP external review
  • Maintain treatment timeline documentation

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for complex medications like Revlimid. Our platform helps patients, clinicians, and specialty pharmacies navigate the prior authorization process by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with payer requirements. For patients facing Cigna denials in New Jersey, Counterforce Health provides the clinical evidence and procedural expertise needed to maximize approval chances through both internal appeals and external reviews.

From Our Advocates

"We've seen multiple cases where initial Revlimid denials were overturned simply by providing complete REMS documentation and clear NCCN guideline alignment. The key is addressing every specific denial reason with clinical evidence rather than submitting generic appeals."

FAQ

Q: How long does Cigna prior authorization take for Revlimid in New Jersey? A: Standard PA decisions are made within 72 hours of complete submission. Urgent requests receive decisions within 24 hours. If Cigna doesn't respond within these timeframes, the request is automatically approved.

Q: What if Revlimid is non-formulary on my Cigna plan? A: You can request a formulary exception with clinical justification. Most plans prefer generic lenalidomide, so document medical necessity for brand Revlimid specifically.

Q: Can I appeal to New Jersey's external review program? A: Yes, if you have a fully insured New Jersey plan. Self-funded ERISA plans and Medicare plans follow federal appeal processes instead of IHCAP.

Q: What counts as medical necessity for Revlimid? A: FDA-approved indications with proper REMS compliance, or NCCN-supported off-label uses with documentation of prior therapy failures and contraindications to alternatives.

Q: Do I need to use Accredo pharmacy? A: Most Cigna plans require specialty medications through Accredo. Verify your specific plan requirements and ensure any alternative pharmacy is REMS-certified.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual plan terms and clinical circumstances. Consult your healthcare provider for medical guidance and review your specific plan documents for coverage details. For assistance with New Jersey insurance appeals, contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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