CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pomalidomide (Pomalyst) — Coverage Criteria for FDA and Compendial Oncology Indications

Defines coverage and authorization criteria for pomalidomide (Pomalyst) for FDA-approved and compendial oncology indications for members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPomalidomide (Pomalyst) — Coverage Criteria for FDA and Compendial Oncology Indications

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization is required; authorization of up to 12 months may be granted when criteria for the specific indication are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsmaximum authorization period for approved indications

>=2 prior therapiesrequirement for FDA multiple myeloma indication

includes compendial usespolicy covers listed compendial indications

Coverage Criteria for Pomalidomide (Pomalyst)

Initial therapy — Multiple Myeloma (FDA)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Multiple Myeloma — alternate combination pathways

Covered when ALL of the following are met for alternative multiple myeloma regimens:

Alternate prior-therapy scenarios: (1) Member has previously received at least one prior therapy including an immunomodulatory agent and a proteasome inhibitor and requested medication will be used in combination with daratumumab and dexamethasone; OR (2) Member has previously received at least one prior therapy and requested medication will be used in combination with carfilzomib and dexamethasone.at least one prior therapy

These are distinct pathways that allow authorization with fewer prior therapies when used in the specified combinations.

Systemic light chain amyloidosis

Covered when ALL of the following are met for systemic light chain amyloidosis:

Systemic light chain amyloidosis: Treatment of relapsed or refractory systemic light chain amyloidosis in combination with dexamethasone.relapsed or refractory

Authorization of 12 months may be granted.

Kaposi sarcoma

Covered when ANY of the following are met for Kaposi sarcoma:

Kaposi Sarcoma: (1) Requested medication will be used in combination with antiretroviral therapy for AIDS-related Kaposi sarcoma; OR (2) Member is HIV-negative.

Authorization of 12 months may be granted.

Continuation/Reauthorization

Continuation of therapy:

Continuation: Authorization of 12 months may be granted for reauthorization when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.no unacceptable toxicity or disease progression

Applies to indications listed in Section II.

Regimen	Coverage status
In combination with elotuzumab + dexamethasone	Authorization criteria: member has previously received ≥2 prior therapies including an immunomodulatory agent and a proteasome inhibitor (or alternate pathways per policy).
In combination with ixazomib + dexamethasone	Authorization criteria: member has previously received ≥2 prior therapies including an immunomodulatory agent and a proteasome inhibitor (or alternate pathways per policy).
In combination with bortezomib + dexamethasone	Authorization criteria: member has previously received ≥2 prior therapies including an immunomodulatory agent and a proteasome inhibitor (or alternate pathways per policy).
In combination with cyclophosphamide + dexamethasone	Authorization criteria: member has previously received ≥2 prior therapies including an immunomodulatory agent and a proteasome inhibitor (or alternate pathways per policy).
In combination with isatuximab-irfc + dexamethasone	Authorization criteria: member has previously received ≥2 prior therapies including an immunomodulatory agent and a proteasome inhibitor (or alternate pathways per policy).
In combination with dexamethasone	Authorization criteria: member has previously received ≥2 prior therapies including an immunomodulatory agent and a proteasome inhibitor (or alternate pathways per policy).
In combination with selinexor + dexamethasone	Authorization criteria: member has previously received ≥2 prior therapies including an immunomodulatory agent and a proteasome inhibitor (or alternate pathways per policy).
As a single agent	Authorization criteria: member has previously received ≥2 prior therapies including an immunomodulatory agent and a proteasome inhibitor (or alternate pathways per policy).
In combination with daratumumab + dexamethasone	Authorization criteria: member has previously received at least one prior therapy including an immunomodulatory agent and a proteasome inhibitor (alternate pathway allowing authorization with one prior therapy).
In combination with carfilzomib + dexamethasone	Authorization criteria: member has previously received at least one prior therapy (alternate pathway allowing authorization with one prior therapy).

Prior Authorization, Documentation, and Provider Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for the medication. Authorization of up to 12 months may be granted when the listed criteria for the specific indication are met.

Documentation Required

Prior Therapy Requirements

For the FDA multiple myeloma indication, the member must have received required prior therapies: at least two prior therapies including lenalidomide (or another immunomodulatory agent) and a proteasome inhibitor, or as specified in the criteria for combination regimens.

Denial Risk

Non‑covered Indications

Indications not listed (outside the FDA-approved indications and the compendial uses listed in this policy) are considered experimental/investigational and are not medically necessary. Examples of compendial uses included in this policy are systemic light chain amyloidosis, primary central nervous system lymphoma, POEMS syndrome, and multiple myeloma per compendia; all other uses are non-covered.

Note

Supporting References

References that may support coverage determinations include the Pomalyst (pomalidomide) package insert and the NCCN Drugs & Biologics Compendium, which may be used to support compendial indications.

Required Line of Therapy

second-line

Line of therapy: At least two prior therapies including lenalidomide and a proteasome inhibitor (for the FDA multiple myeloma indication) or specified one-prior-therapy combinations when used with certain agents.see text

Different regimen combinations allow authorization with one prior therapy in specified circumstances.

Definitions and Compendial Uses

Compendial uses — definition and implications

DefinitionIndications listed in recognized clinical compendia (e.g., NCCN Drugs & Biologics Compendium) that are considered covered when the policy's approval criteria are met.

Examples of compendial uses included in this policySystemic light chain amyloidosis; Primary central nervous system lymphoma; POEMS syndrome; Multiple myeloma (compendial pathway).

Coverage implicationCompendial indications are eligible for authorization when the specific coverage criteria for that indication in Section II are satisfied.

Non-compendial indicationsAll indications not listed in the compendia are considered experimental/investigational and not medically necessary.

Supporting referencesPolicy references the NCCN Drugs & Biologics Compendium as the recognized compendium used to define compendial uses.

Background on Pomalidomide

Pomalidomide is an immunomodulatory agent with labeled and compendial oncology indications. Per the compendial section of this policy, recognized compendial uses include systemic light chain amyloidosis, primary central nervous system lymphoma, POEMS syndrome, and multiple myeloma. Indications not listed in the FDA or compendial sections are considered experimental/investigational and not medically necessary.