CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pomalyst 2234 A Sgm P2023

Defines clinical coverage and authorization criteria for pomalidomide (Pomalyst) including FDA-approved indications and select compendial uses, duration of authorization (typically 12 months), and continuation criteria for reauthorization. Applies when all listed approval criteria are met and member has no exclusions to therapy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPomalyst 2234 A Sgm P2023

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required and authorization of 12 months may be granted when the specified clinical criteria for the applicable indication are met.

SourceLink

POLICY UPDATE CHANGES

No material changes to policy content or coverage criteria.

6Covered Indications Listed

12Authorization Duration

1-2Prior therapy requirement

Coverage Summary & Indications

Pomalyst (pomalidomide) coverage follows FDA-approved indications and selected compendial uses (NCCN). The policy defines regimen-specific prior therapy requirements for multiple myeloma and grants 12-month authorizations for approved uses. Continuation or reauthorization may be granted for 12 months when there is no evidence of unacceptable toxicity and no evidence of disease progression while on the current regimen.

Provider Actions & Prior Authorization

Prior Authorization

Authorization required

Prior authorization is required and authorization of 12 months may be granted when the specified clinical criteria for the applicable indication are met.

Documentation Required

Documentation of prior therapies and refractory status

Provider must document prior therapies (number and classes received, e.g., immunomodulatory agent and proteasome inhibitor) and relevant refractory status (e.g., lenalidomide refractory) to meet regimen-specific criteria.

Denial Risk

Not covered for unlisted indications

Requests for indications not listed (i.e., not FDA-approved or compendial as specified) will be considered experimental/investigational and are not medically necessary — risk of denial.

Clinical Evidence & References

Pomalyst package insert (March 2023); NCCN Drugs & Biologics Compendium (accessed Oct 4, 2023).

Lenalidomide refractory: Term used in regimen-specific criteria to indicate disease not responding to lenalidomide; the provider must document refractory status.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPomalyst 2234 A Sgm P2023

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required and authorization of 12 months may be granted when the specified clinical criteria for the applicable indication are met.

SourceLink

On This Page

OpenPayer

Pomalyst 2234 A Sgm P2023

Coverage Summary & Indications

Compendial Uses & Exclusions

Continuation of Therapy / Reauthorization

Provider Actions & Prior Authorization

Applicable Codes

Clinical Evidence & References

Revision History