By Counterforce Health Team in Pomalyst (pomalidomide) —

Get Pomalyst (Pomalidomide) Covered by Aetna CVS Health in California: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Pomalyst Covered by Aetna CVS Health in California

Pomalyst (pomalidomide) requires prior authorization from Aetna CVS Health, REMS program enrollment, and specialty pharmacy dispensing. Success depends on documenting prior therapy failures (lenalidomide + proteasome inhibitor) and completing all REMS requirements.

Fast track to approval:

  1. Enroll in PS-Pomalidomide REMS program (patient and prescriber)
  2. Submit Aetna PA with complete prior therapy documentation
  3. Fill only at CVS Specialty or REMS-certified pharmacy

Start today: Call BMS Access Support at 1-800-861-0048 to begin REMS enrollment while your oncologist prepares the prior authorization request.

Table of Contents

Coverage Requirements at a Glance

Requirement Details Source
Prior Authorization Required for all Aetna plans Aetna Precertification List
Formulary Tier Tier 5 (Specialty) - 25-33% coinsurance Aetna Drug Guide
REMS Enrollment Mandatory for prescriber and patient FDA REMS
Specialty Pharmacy CVS Specialty or REMS-certified only CVS Specialty Forms
Prior Therapies Must document lenalidomide + PI failure Aetna Policy
Prescriber Oncologist/hematologist preferred Aetna Coverage Policy

Step-by-Step: Fastest Path to Approval

1. Begin REMS Enrollment (Day 1)

Who: Patient and prescribing oncologist
Action: Visit PS-Pomalidomide REMS website or call BMS Access Support at 1-800-861-0048
Timeline: 1-3 business days for completion
Required: Patient-Physician Agreement Form, pregnancy testing plan (if applicable)

2. Gather Prior Therapy Documentation (Days 1-2)

Who: Clinical team
Documents needed:

  • Complete treatment timeline with dates
  • Proof of lenalidomide (Revlimid) exposure and progression
  • Documentation of proteasome inhibitor failure (bortezomib, carfilzomib, or ixazomib)
  • Recent labs and imaging showing disease progression
  • Pathology confirming multiple myeloma diagnosis

3. Submit Prior Authorization (Day 3-4)

Who: Prescriber or clinic staff
Method: Availity provider portal (preferred) or Aetna PA forms
Include: REMS authorization number, clinical notes, prior therapy timeline, ICD-10 codes
Timeline: Standard review within 30 days; expedited available for urgent cases

4. Monitor PA Status (Ongoing)

Action: Check Availity portal or call Aetna Provider Services
Response: Reply quickly to any requests for additional information
Backup: Request peer-to-peer review if initial denial

5. Coordinate Specialty Pharmacy (Upon Approval)

Pharmacy: CVS Specialty (for Aetna members) at 1-800-237-2767
Required: REMS completion confirmation, valid PA approval
Timeline: 2-3 business days for first fill after approval

Prior Authorization Essentials

Medical Necessity Documentation

Your oncologist's PA request must include:

  • Diagnosis: Multiple myeloma with ICD-10 code C90.00-C90.02
  • Prior therapies: Specific dates and outcomes for:
    • Lenalidomide (Revlimid) - must show progression within 60 days
    • Proteasome inhibitor (bortezomib, carfilzomib, or ixazomib) - document failure or intolerance
  • Current status: Recent labs (M-protein, free light chains), imaging, bone marrow biopsy results
  • Treatment plan: Pomalyst 4mg daily (days 1-21 of 28-day cycle) with dexamethasone
Clinician Corner: The medical necessity letter should reference NCCN Multiple Myeloma Guidelines and FDA labeling for third-line therapy. Include specific progression dates and why alternative therapies aren't suitable.

Common PA Submission Errors

  • Incomplete REMS documentation
  • Missing specific dates of prior therapy failures
  • Non-specialist prescriber without consultation notes
  • Lack of combination therapy plan (dexamethasone)

REMS Program Requirements

The PS-Pomalidomide REMS program is mandatory due to severe birth defect risks. Both prescriber and patient must complete separate enrollments.

Prescriber Requirements

  • Complete REMS training and certification
  • Attest to patient counseling on risks
  • Provide Patient-Physician Agreement Form for each prescription

Patient Requirements

  • Sign Patient-Physician Agreement Form
  • Complete pregnancy testing (if applicable)
  • Agree to contraception requirements
  • Understand distribution restrictions

Timeline: REMS completion typically takes 1-3 business days. BMS Access Support provides step-by-step guidance and tracks enrollment status.

Cost and Financial Assistance

Aetna Coverage Costs

  • Tier 5 Specialty: 25-33% coinsurance (varies by plan)
  • Retail cost: Approximately $23,400 per 21-capsule pack
  • Your cost: $5,850-$7,722 per month without assistance

BMS Access Support Programs

Co-Pay Assistance Card (Commercial Insurance Only)

  • Eligibility: Commercially insured, not on government programs
  • Application: BMS Co-Pay Program or call 1-800-861-0048
  • Savings: Significant reduction in out-of-pocket costs

Patient Assistance Foundation

Independent Foundations

  • Leukemia & Lymphoma Society Patient Aid Program
  • CancerCare Co-Payment Assistance Foundation
  • Patient Access Network Foundation
Note: Government insurance beneficiaries (Medicare, Medicaid) cannot use manufacturer co-pay cards but may qualify for foundation assistance.

Appeals Process in California

If Aetna denies your PA request, California provides strong appeal rights through multiple levels.

Internal Appeals with Aetna

  • Timeline: File within 180 days of denial
  • Standard review: 30-45 days for decision
  • Expedited review: 72 hours for urgent cases
  • Method: Online portal, phone, or written request

California Independent Medical Review (IMR)

After exhausting internal appeals, California residents can request external review.

For DMHC-regulated plans (most HMOs):

  • Contact: DMHC Help Center at 888-466-2219
  • Timeline: 45 days for standard IMR, 7 days for expedited
  • Cost: Free to patients
  • Success rate: Approximately 12% for pharmaceutical appeals

Required documentation for IMR:

  • Complete denial letters from Aetna
  • All medical records supporting medical necessity
  • Scientific literature supporting Pomalyst use
  • Statement from treating oncologist
From our advocates: "We've seen denials overturned when families included peer-reviewed studies showing Pomalyst's efficacy in similar clinical situations, along with detailed documentation of why other therapies weren't suitable. The key is comprehensive evidence, not just clinical opinion."

Common Denial Reasons & Solutions

Denial Reason How to Overturn Documentation Needed
Incomplete REMS Complete all REMS requirements REMS authorization number, Patient-Physician Agreement
Insufficient prior therapy Document specific failures Treatment timelines with dates, progression notes, lab results
Non-specialist prescriber Obtain oncology consultation Hematology/oncology consultation note or co-signature
Missing combination therapy Include dexamethasone plan Prescription for both agents, dosing schedule
"Experimental" designation Provide FDA approval evidence FDA label, NCCN guidelines, clinical studies

When to Request External Review

Consider escalating to California's Independent Medical Review if:

  • Aetna upholds denial after internal appeal
  • Denial is based on "not medically necessary"
  • You have strong clinical evidence supporting treatment
  • Your oncologist strongly recommends Pomalyst as appropriate therapy

Contact Information:

  • DMHC Help Center: 888-466-2219
  • Online IMR application: healthhelp.ca.gov
  • CDI Consumer Hotline: 800-927-4357 (for CDI-regulated plans)

FAQ

Q: How long does Aetna prior authorization take for Pomalyst?
A: Standard PA review takes up to 30 days. Expedited review (for urgent medical need) can be completed within 72 hours. REMS enrollment adds 1-3 business days before approval is possible.

Q: Can I fill Pomalyst at my regular pharmacy?
A: No. Pomalyst must be dispensed through REMS-certified specialty pharmacies only. For Aetna members, this is typically CVS Specialty at 1-800-237-2767.

Q: What if Pomalyst isn't on my Aetna formulary?
A: Pomalyst is typically covered as a Tier 5 specialty drug. If non-formulary, request a formulary exception with clinical documentation showing medical necessity and lack of suitable alternatives.

Q: Does step therapy apply if I've already failed lenalidomide?
A: You must document specific failure of both lenalidomide and a proteasome inhibitor. Previous failures outside California count if properly documented.

Q: Can I appeal if my income is too high for patient assistance?
A: Yes. Independent foundations like Patient Access Network Foundation have different eligibility criteria and may provide assistance when manufacturer programs don't qualify.

Q: How much will I pay with Aetna coverage?
A: As a Tier 5 specialty drug, expect 25-33% coinsurance ($5,850-$7,722 monthly) unless you qualify for manufacturer co-pay assistance or foundation grants.

Q: What happens if my appeal is denied?
A: California residents can request Independent Medical Review (IMR) through the Department of Managed Health Care. This external review is binding and free to patients.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create compelling appeals that align with payer requirements, significantly improving approval rates for complex specialty medications like Pomalyst.

When navigating Aetna's prior authorization process, having the right documentation and understanding payer-specific requirements can make the difference between approval and denial. Counterforce Health streamlines this process by identifying exactly what evidence Aetna needs and crafting appeals that speak directly to their coverage criteria.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance company for plan-specific requirements. Coverage policies and procedures may change; verify current requirements with your insurer.

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