By Counterforce Health Team in Pomalyst (pomalidomide) —

Do You Qualify for Pomalyst (pomalidomide) Coverage by Cigna in Michigan? Decision Tree & Next Steps

Answer Box: Quick Qualification Check

Most likely to qualify: Patients 18+ with multiple myeloma who've failed both lenalidomide (Revlimid) and a proteasome inhibitor (like bortezomib), with documented progression within 60 days of last therapy. Fastest path: Have your oncologist submit prior authorization through Cigna's provider portal with complete therapy timeline and REMS enrollment confirmation. Start today: Call your oncologist's office to request they begin the PA process and confirm you're enrolled in the Pomalyst REMS program.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Decision Tree
  3. If You're "Likely Eligible"
  4. If You're "Possibly Eligible"
  5. If You're "Not Yet Eligible"
  6. If Denied: Appeal Path Chooser
  7. Visual Decision Flowchart
  8. Resources & Verification

How to Use This Guide

This decision tree helps you determine your likelihood of getting Pomalyst (pomalidomide) covered by Cigna in Michigan before you start the prior authorization process. Work through each section based on your current situation.

What you'll need to check:

  • Your complete multiple myeloma treatment history
  • Current Cigna plan details (member ID, formulary tier)
  • Access to your oncologist's office for clinical documentation

Time investment: 10-15 minutes to work through the decision tree, plus coordination time with your healthcare team.

Eligibility Decision Tree

Step 1: Diagnosis Confirmation

✓ Do you have a confirmed diagnosis of multiple myeloma?

  • Yes: Continue to Step 2
  • No: Pomalyst is also FDA-approved for Kaposi sarcoma in specific situations. Consult your oncologist about alternative coverage pathways.

Step 2: Age Requirement

✓ Are you 18 years or older?

According to Cigna's coverage policy, patients must be 18+ for multiple myeloma coverage.

  • Yes: Continue to Step 3
  • No: Coverage unlikely under current policy

Step 3: Prior Therapy Requirements

✓ Have you tried and failed at least one other regimen that included BOTH:

  • Lenalidomide (Revlimid), AND
  • A proteasome inhibitor (such as bortezomib/Velcade, carfilzomib/Kyprolis, or ixazomib/Ninlaro)?
  • Yes, both: → "Likely Eligible" (proceed to Section 3)
  • Yes, but only one: → "Possibly Eligible" (proceed to Section 4)
  • No, neither: → "Not Yet Eligible" (proceed to Section 5)

Step 4: REMS Program Status

✓ Are you enrolled in the Pomalyst REMS program?

This federal requirement applies to all patients receiving pomalidomide due to serious birth defect risks.

  • Yes: Maintain current status
  • No: Your prescriber must enroll you before any approval
  • Unsure: Contact your oncologist's office to verify

If You're "Likely Eligible"

Congratulations! You meet Cigna's basic coverage criteria. Here's your approval checklist:

Document Checklist

Your oncologist's office needs to submit:

Document Details Required Source
Prior Authorization Form Complete PA request via Cigna provider portal Cigna PA Process
Treatment Timeline Dates of lenalidomide and proteasome inhibitor use, progression dates Clinical records
REMS Enrollment Confirmation of patient/prescriber certification REMS program database
Clinical Notes Diagnosis confirmation, current disease status Oncologist documentation
Combination Therapy Plan Intended use with dexamethasone (if applicable) Treatment protocol

Submission Path

  1. Oncologist initiates: Your cancer specialist submits the PA through Cigna's provider portal
  2. Timeline: Cigna reviews within 5 business days (72 hours for urgent requests)
  3. Specialty pharmacy: If approved, prescription routes through Express Scripts/Accredo
  4. REMS compliance: Final verification before first shipment

Expected Timeline

  • PA submission: 1-2 business days (your oncologist's office)
  • Cigna review: Up to 5 business days
  • Approval to shipment: 3-5 additional days through specialty pharmacy

If You're "Possibly Eligible"

You're missing one key requirement but may still qualify with additional documentation.

Missing Lenalidomide History?

What to track:

  • Document any lenalidomide exposure, even if brief
  • Note reasons for discontinuation (progression, intolerance, access issues)
  • Consider if you received it as part of initial therapy or maintenance

Timeline to reapply: Once you have complete documentation

Missing Proteasome Inhibitor History?

Tests to request from your oncologist:

  • Review all prior treatment regimens for any PI exposure
  • Consider clinical trial participation that may have included PIs
  • Document reasons if PIs were avoided (contraindications, toxicity concerns)

Alternative approach: Request a formulary exception based on medical necessity if standard therapy isn't appropriate for your case.

If You're "Not Yet Eligible"

Your treatment history doesn't yet meet Cigna's standard criteria, but you have options.

Alternatives to Discuss

With your oncologist:

  • Lenalidomide-based regimens (if not previously tried)
  • Proteasome inhibitor combinations
  • Clinical trial opportunities
  • Anti-CD38 antibody treatments (daratumumab)

Prepare for Exception Requests

Medical necessity arguments:

  • Contraindications to standard therapies
  • Unique clinical circumstances
  • Rapid disease progression requiring immediate alternative therapy

Documentation needed:

  • Detailed clinical rationale from oncologist
  • Literature supporting pomalidomide in your specific situation
  • Evidence that standard approaches aren't suitable

If Denied: Appeal Path Chooser

Level 1: Cigna Internal Appeal

Deadline: 180 days from denial notice Timeline: 30 days for medical necessity decisions

Submit to Cigna:

  • Customer Appeal Form
  • Copy of denial letter
  • Additional clinical documentation
  • Updated physician letter addressing denial reasons

Level 2: Peer-to-Peer Review

When to request: If initial appeal focuses on medical necessity Process: Your oncologist speaks directly with Cigna's medical director Timeline: Usually scheduled within 1-2 weeks of request

Level 3: Michigan External Review

When available: After exhausting Cigna's internal appeals Deadline: 127 days from final internal denial (Michigan-specific timeline) Authority: Michigan Department of Insurance and Financial Services (DIFS)

Submit to DIFS:

  • External Review Request Form (verify current link)
  • All Cigna denial and appeal documentation
  • Updated clinical evidence
  • Physician support letter

Contact DIFS: 877-999-6442 for forms and guidance

From our advocates: In our experience helping patients navigate Cigna denials in Michigan, the most successful appeals include a detailed timeline showing exactly when each prior therapy was tried, how long it was used, and specific dates of disease progression. This concrete documentation often addresses Cigna's most common denial reasons and can turn a "no" into approval at the first appeal level.

Visual Decision Flowchart

Multiple Myeloma Diagnosis?
├─ Yes → Age 18+?
│   ├─ Yes → Prior Lenalidomide + PI?
│   │   ├─ Both → LIKELY ELIGIBLE
│   │   ├─ One → POSSIBLY ELIGIBLE  
│   │   └─ Neither → NOT YET ELIGIBLE
│   └─ No → Coverage Unlikely
└─ No → Consider Alternative Indications

Download: Request a printable PDF version through Counterforce Health, which specializes in turning insurance denials into targeted, evidence-backed appeals for patients navigating complex prior authorization requirements.

Resources & Verification

Official Sources

When to Get Help

Contact Counterforce Health if:

  • Your case doesn't fit standard criteria
  • You've received multiple denials
  • You need help crafting a medical necessity argument
  • Appeals deadlines are approaching

Michigan DIFS Consumer Hotline: 877-999-6442 for insurance complaint assistance

Frequently Asked Questions

Q: How long does Cigna prior authorization take in Michigan? A: Up to 5 business days for standard requests, 72 hours for urgent cases requiring immediate treatment.

Q: What if Pomalyst is non-formulary on my plan? A: Request a formulary exception with clinical justification. Your oncologist can argue medical necessity if covered alternatives aren't appropriate.

Q: Can I request an expedited appeal in Michigan? A: Yes, both Cigna and Michigan DIFS offer expedited reviews when delays would harm your health. Requires physician documentation of urgency.

Q: Does step therapy apply if I failed therapies outside Michigan? A: No, prior therapy failures from any location count toward meeting Cigna's requirements, provided documentation is available.

Q: What financial assistance is available for Michigan residents? A: BMS offers copay cards (commercial insurance) and patient assistance foundation programs (uninsured/underinsured). Income and insurance restrictions apply.

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not replace professional medical advice. Coverage decisions depend on individual plan details and clinical circumstances. Always verify current policy requirements with your insurer and consult your healthcare team for treatment decisions. For personalized assistance with insurance appeals and prior authorizations, consider consulting with coverage specialists who understand the complexities of oncology drug approvals.

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