By Counterforce Health Team in Pomalyst (pomalidomide) —

Get Pomalyst (Pomalidomide) Covered by Blue Cross Blue Shield in New York: Complete Appeals Guide

Answer Box: Fastest Path to Pomalyst Coverage

Pomalyst (pomalidomide) requires prior authorization from Blue Cross Blue Shield plans in New York. Success depends on documenting progression after ≥2 prior therapies including lenalidomide and a proteasome inhibitor, REMS program enrollment, and oncologist prescription with dexamethasone combination. If denied, New York's external review through DFS provides binding decisions within 30 days (72 hours expedited). Start today: Have your oncologist submit PA documentation including prior therapy timeline, progression scans, and REMS enrollment confirmation via your plan's provider portal.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Medical Necessity Criteria
  5. Costs and Financial Assistance
  6. Denials and Appeals
  7. REMS Program Requirements
  8. Specialty Pharmacy Networks
  9. Common Problems and Solutions
  10. FAQ

Coverage Basics

Is Pomalyst Covered by Blue Cross Blue Shield in New York?

Most Blue Cross Blue Shield plans in New York cover Pomalyst (pomalidomide) as a specialty medication requiring prior authorization. Coverage varies by specific plan formulary:

Plan Type Typical Coverage Tier Requirements
Commercial/Employer Covered with PA 3-4 (Specialty) Oncologist Rx, REMS enrollment
Individual/Marketplace Covered with PA 3-4 (Specialty) Same as commercial
Medicare Advantage Plan-specific Varies May have additional step therapy
Note: Excellus BCBS (NY affiliate) lists Pomalyst under oncology prior authorization with quantity limits of 21 tablets per 28 days.

Which Blue Cross Blue Shield Plans Apply?

New York has several Blue Cross Blue Shield affiliates:

  • Empire BlueCross BlueShield (Anthem subsidiary)
  • Excellus BlueCross BlueShield (Rochester/Central NY)
  • Independent Health (Western NY)

Each maintains separate formularies, so verify your specific plan's coverage by calling the member services number on your insurance card.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify REMS Enrollment (Patient + Prescriber)
    • Register at POMALYST REMS program
    • Complete Patient-Physician Agreement Form
    • Timeline: 1-2 business days
  2. Gather Documentation (Clinic Staff)
    • Prior therapy records (lenalidomide + proteasome inhibitor)
    • Progression scans/labs within 60 days of last treatment
    • Current lab values (ANC ≥500/mm³, platelets ≥50,000/mm³)
  3. Submit Prior Authorization (Prescriber)
    • Use plan's provider portal or ePA system
    • Include ICD-10 code C90.02 (multiple myeloma)
    • Attach medical necessity letter with NCCN guidelines
  4. Track Status (Patient/Clinic)
    • Standard review: 72 hours
    • Expedited review: 24 hours if health risk documented
Tip: Bristol Myers Squibb Access Support (1-800-861-0048) provides PA forms and reimbursement guidance specific to your Blue Cross Blue Shield plan.

Who Submits the Prior Authorization?

Your oncologist or hematologist must submit the PA request. Pomalyst requires specialist prescribing due to its complexity and REMS requirements. Primary care physicians typically cannot prescribe or obtain authorization for this medication.

Timing and Urgency

How Long Does Blue Cross Blue Shield PA Take in New York?

Review Type Timeline When to Use
Standard 72 hours Routine treatment planning
Expedited 24 hours Oncologist certifies health risk from delay
Emergency Same-day Life-threatening situations

What if Treatment is Urgent?

If your oncologist determines that delaying Pomalyst poses a serious health risk, request expedited review. Include documentation of:

  • Disease progression requiring immediate treatment
  • Risk of complications from delay
  • Why alternative treatments aren't suitable

New York law requires insurers to process urgent requests within 24 hours for specialty drugs.

Medical Necessity Criteria

What Counts as Medical Necessity for Pomalyst?

Based on FDA labeling and typical Blue Cross Blue Shield policies, Pomalyst is considered medically necessary for:

Primary Indication:

  • Relapsed/refractory multiple myeloma
  • After ≥2 prior therapies including:
    • Lenalidomide (Revlimid)
    • Proteasome inhibitor (bortezomib, carfilzomib, or ixazomib)
  • Disease progression on or within 60 days of last therapy

Required Documentation:

  • Pathology confirming multiple myeloma diagnosis
  • Treatment history with dates and outcomes
  • Imaging showing disease progression
  • Lab values meeting safety thresholds
  • Plan for dexamethasone combination therapy

Clinician Corner: Medical Necessity Letter Checklist

For Prescribers: Your medical necessity letter should include:

✓ Problem: Relapsed/refractory multiple myeloma with progression ✓ Prior Treatments: Specific dates, drugs, doses, and reasons for discontinuation ✓ Clinical Rationale: NCCN Category 1 recommendation for pomalidomide-dexamethasone ✓ Monitoring Plan: CBC weekly x8 weeks, pregnancy testing, VTE prophylaxis ✓ REMS Compliance: Confirmation of program enrollment and ongoing requirements

Costs and Financial Assistance

What Does Pomalyst Cost with Blue Cross Blue Shield?

Costs vary significantly by plan design:

Plan Feature Typical Range Notes
Deductible $0-$8,000+ Must be met before coverage
Copay $50-$500/month Fixed amount
Coinsurance 10-50% Percentage of drug cost
Out-of-pocket max $2,000-$9,450 Annual protection limit

Retail cash price: ~$23,400 per 28-day cycle (21 capsules)

Bristol Myers Squibb Copay Assistance

The BMS Access Support Co-Pay Assistance Program offers $0 copay for eligible commercially insured patients, including those with Blue Cross Blue Shield plans.

Eligibility:

  • Commercial insurance (not Medicare/Medicaid)
  • U.S. residents
  • Prescribed Pomalyst for approved indication

How to Apply:

  • Call 1-800-861-0048
  • Visit bmscopay.com for instant online enrollment
  • Use virtual card at pharmacy

Additional Financial Resources

Program Eligibility Benefit Contact
PAF Co-Pay Relief Income ≤500% FPL, Medicare/Medicaid Up to $7,500/year 1-866-512-3861
QuickRx Copay Assistance Multiple myeloma patients $0 copay for eligible quickrxspecialty.pharmacy
Simplefill Ongoing treatment Program matching (877) 386-0206

Denials and Appeals

Common Denial Reasons & How to Fix Them

Denial Reason Solution Documents
Insufficient prior therapy Pharmacy records, treatment timeline, progression scans
REMS not completed REMS enrollment confirmation, Patient-Physician Agreement
Non-specialist prescriber Transfer to oncologist/hematologist
Missing dexamethasone Updated prescription showing combination therapy
Lab values out of range Recent CBC showing ANC ≥500, platelets ≥50k

Appeals Playbook for Blue Cross Blue Shield in New York

Level 1: Internal Appeal

  • Deadline: 180 days from denial
  • Timeline: 30 days for decision (expedited: 72 hours)
  • How to file: Call member services or submit via member portal
  • Required: Denial letter, medical records, prescriber letter

Level 2: External Review (New York DFS)

  • Deadline: 4 months from final internal denial
  • Timeline: 30 days (expedited: 72 hours, urgent: 24 hours)
  • How to file:
    • Online: DFS External Appeal Portal
    • Mail: NY DFS, 99 Washington Ave, Box 177, Albany, NY 12210
    • Fax: (800) 332-2729
  • Cost: $25 maximum (waived for financial hardship)
  • Outcome: Binding on insurer
From Our Advocates: We've seen multiple myeloma patients successfully overturn Pomalyst denials by submitting a comprehensive timeline showing lenalidomide failure followed by proteasome inhibitor progression. The key is demonstrating clear disease advancement despite appropriate prior therapies, supported by imaging and lab trends.

When to Escalate Beyond Appeals

If external review is unsuccessful (rare), additional options include:

  • ERISA appeal (for employer plans)
  • State insurance complaint via NY Department of Financial Services
  • Legal consultation for potential bad faith denial

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to craft point-by-point rebuttals aligned with the insurer's own rules.

REMS Program Requirements

Mandatory POMALYST REMS Enrollment

All Pomalyst dispensing requires participation in the POMALYST REMS program due to severe birth defect risks.

Prescriber Requirements:

  • Register and become certified with POMALYST REMS
  • Complete prescriber training
  • Submit Patient-Physician Agreement Forms

Patient Requirements:

  • Sign Patient-Physician Agreement
  • Females of reproductive potential:
    • Negative pregnancy test before each cycle
    • Use contraception during therapy + 4 weeks after
  • Males (or females with male partners):
    • Use latex/synthetic condoms during therapy + 4 weeks after

Pharmacy Requirements:

  • Enroll in REMS program
  • Dispense only to REMS-authorized patients
  • Verify enrollment before each fill
Important: REMS non-compliance will block Pomalyst access regardless of insurance approval.

Specialty Pharmacy Networks

Why Was Pomalyst Transferred to Specialty Pharmacy?

Blue Cross Blue Shield plans typically require specialty medications like Pomalyst to be filled through designated specialty pharmacies due to:

  • REMS program compliance requirements
  • Complex handling and storage needs
  • Specialized patient monitoring
  • Prior authorization coordination

While specific Blue Cross Blue Shield New York specialty networks weren't identified in available sources, most plans use limited distribution networks for REMS medications.

To verify your plan's specialty pharmacy:

  • Call member services number on insurance card
  • Contact BMS Access Support at 1-800-861-0048
  • Check provider portal for network pharmacy list

Common Problems and Solutions

Troubleshooting Checklist

Portal/System Issues:

  • ✓ Verify current provider portal URL with plan
  • ✓ Check for planned maintenance windows
  • ✓ Use alternative submission methods (fax/phone)

Missing Forms:

  • ✓ Download current PA forms from plan website
  • ✓ Contact BMS Access Support for assistance
  • ✓ Verify REMS documentation is complete

Status Delays:

  • ✓ Call member services for status updates
  • ✓ Request expedited review if clinically appropriate
  • ✓ Escalate to supervisor if standard timelines exceeded

Pharmacy Issues:

  • ✓ Confirm pharmacy is REMS-enrolled
  • ✓ Verify patient REMS status is current
  • ✓ Check for quantity limit restrictions

Frequently Asked Questions

How long does Blue Cross Blue Shield PA take for Pomalyst in New York? Standard review takes 72 hours; expedited review (when oncologist documents health risk) takes 24 hours.

What if Pomalyst is non-formulary on my Blue Cross Blue Shield plan? Request a formulary exception with medical necessity documentation. Include evidence that formulary alternatives have failed or are contraindicated.

Can I request expedited appeal if denied? Yes, if your oncologist certifies that delay poses serious health risks. Expedited appeals receive decisions within 72 hours.

Does step therapy apply if I failed treatments outside New York? Under New York's 2026 step therapy law, prior failures covered by your current Blue Cross Blue Shield plan in the past 365 days qualify for automatic bypass, regardless of treatment location.

What happens if external review denies coverage? External review decisions are binding, but you may pursue ERISA appeals (employer plans) or legal consultation for potential bad faith denial.

How do I find my Blue Cross Blue Shield plan's formulary? Visit your plan's website or call member services. For Empire BCBS, check anthem.com/ny/pharmacy-information/drug-list. For Excellus, visit excellusbcbs.com/plans.

Can I get help with the appeal process? Yes. Counterforce Health helps patients and clinicians turn insurance denials into targeted appeals by analyzing plan policies and crafting evidence-backed rebuttals. Community Health Advocates also provides free counseling at 888-614-5400.

What if I can't afford Pomalyst even with insurance? Contact BMS Access Support (1-800-861-0048) for copay assistance. Additional programs include PAF Co-Pay Relief for Medicare/Medicaid patients and various foundation grants for multiple myeloma treatment.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult your healthcare provider and insurance plan directly for specific coverage determinations. For personalized assistance with insurance appeals and prior authorizations, consider consulting with Counterforce Health, which specializes in helping patients navigate complex coverage challenges for specialty medications.

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