By Counterforce Health Team in Pomalyst (pomalidomide) —

Getting Pomalyst (Pomalidomide) Covered by Cigna in Texas: Prior Authorization, Appeals, and State Protection Guide

Answer Box: Your Fastest Path to Coverage

Getting Pomalyst (pomalidomide) covered by Cigna in Texas requires prior authorization with proof of multiple myeloma diagnosis, failure of lenalidomide and a proteasome inhibitor, and REMS enrollment. If denied, you have 180 days to appeal internally, then can request Texas Independent Review Organization (IRO) review within 45 days of final denial. Start today: Have your oncologist submit PA through ExpressPAth or CoverMyMeds with detailed prior therapy timeline and NCCN guideline citation.

Table of Contents

Why Texas State Rules Matter

Texas insurance law provides specific protections that can override restrictive plan policies—especially important for expensive specialty drugs like Pomalyst (pomalidomide). While Cigna manages specialty medications through Express Scripts and Accredo, Texas Insurance Code requires clear step therapy exception processes and mandates external review rights for medical necessity denials.

Understanding these state-level protections is crucial because:

  • Step therapy overrides must be granted if you've previously failed required drugs or they're contraindicated
  • IRO external review provides binding decisions when Cigna denies coverage for medical necessity
  • Expedited timelines apply when delays could jeopardize your health
Note: Self-funded employer plans (ERISA) follow federal rules instead of Texas state protections, though similar appeal rights typically apply.

Coverage Requirements at a Glance

Requirement What Cigna Needs Where to Find It Timeline
Prior Authorization Clinical documentation via ExpressPAth/CoverMyMeds Cigna PA Portal 7-14 business days
Medical Necessity Multiple myeloma diagnosis, ≥2 prior therapies failed Oncologist notes, treatment timeline Required for approval
REMS Enrollment PS-Pomalidomide program certification POMALYST REMS Must be active
Step Therapy Failed lenalidomide + proteasome inhibitor Pharmacy records, provider attestation Can be overridden
Formulary Status Specialty tier (typically $150+ copay) Plan formulary document Varies by plan

Prior Authorization Turnaround Standards

Cigna must respond to Pomalyst PA requests within specific timeframes under Texas law:

Standard Review: 7-14 business days after receiving complete clinical documentation Expedited Review: 24-72 hours when prescriber documents serious health risk

For urgent cases, your oncologist should explicitly request expedited review and explain why delays could harm your health. This is particularly important for multiple myeloma patients experiencing rapid disease progression.

Renewal Requirements: Most approvals are granted for 6-12 months, requiring reauthorization with updated disease status and continued medical necessity documentation.

Step Therapy Protections in Texas

Texas Insurance Code Section 1369.0546 requires health plans to grant step therapy exceptions when medically appropriate. For Pomalyst, this is especially relevant since most plans require trying lenalidomide (Revlimid) first.

Medical Exception Criteria (Any One Qualifies):

  • Previous failure: You've already tried and failed lenalidomide or a proteasome inhibitor
  • Contraindication: The required step drug is medically inappropriate for you
  • Harm likely: The step therapy drug will likely cause significant adverse effects
  • Ineffectiveness expected: Clinical evidence suggests the required drug won't work
  • Current stability: You're already stable on Pomalyst under previous coverage

How to Request Override:

  1. Your oncologist submits the standard Texas step therapy exception form
  2. Include detailed clinical rationale citing one of the above criteria
  3. Attach documentation of prior therapy attempts and outcomes
  4. Automatic approval if Cigna doesn't respond within 72 hours (24 hours for urgent cases)

Continuity of Care Rights

Texas law (effective September 2025) provides strong protections if your oncologist leaves their practice or if coverage changes interrupt your treatment:

During Provider Transitions:

  • Non-compete agreements cannot prevent your doctor from continuing cancer treatment during acute illness
  • You're entitled to access medical records within 12 months of treatment
  • Practices must provide clear notice of physician departures

During Insurance Changes:

  • While Texas doesn't mandate specialty drug grace periods, federal rules often provide 30-day transition supplies for new enrollees
  • Contact Cigna immediately if coverage gaps arise during plan transitions

External Review & Complaint Process

If Cigna denies your Pomalyst coverage after internal appeals, Texas provides Independent Review Organization (IRO) external review—a binding decision process.

IRO Process Steps:

  1. Complete internal appeal first (unless life-threatening condition)
  2. Submit Form LHL009 within 45 days of final internal denial
  3. TDI assigns certified IRO within 1 business day
  4. IRO reviews case within 20 days (faster for urgent cases)
  5. Decision is binding unless appealed to Administrative Law Judge within 20 days

Contact for IRO Questions: Texas Department of Insurance at 866-554-4926

Appeals Playbook for Cigna

Internal Appeal (First Level)

Timeline: Must file within 180 days of denial How to Submit: Cigna member portal, mail, or fax as directed in denial letter Decision Time: 30 calendar days (72 hours for expedited) Required Documents:

  • Copy of denial letter
  • Prescriber letter of medical necessity
  • Treatment timeline showing prior therapy failures
  • NCCN guideline citation supporting Pomalyst use

Expedited Internal Appeal

When to Use: Disease progression risk, hospitalization likely, or treatment delay dangerous Timeline: 72 hours for decision (24 hours in urgent cases) Key Phrase: Have your doctor write "expedited review requested due to serious health risk"

External Review (IRO)

Timeline: Within 45 days of final internal denial Cost: Cigna pays IRO fees Success Rate: Higher when specialty drug guidelines support medical necessity

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Prior therapies not documented" Submit detailed treatment timeline Pharmacy records, infusion logs, provider notes
"Not refractory to lenalidomide" Prove progression within 60 days Labs showing disease progression, imaging reports
"REMS not enrolled" Complete PS-Pomalidomide certification REMS enrollment confirmation
"Non-specialist prescriber" Transfer prescription to oncologist Hematology/oncology board certification
"Missing dexamethasone combination" Clarify treatment plan Prescription for both drugs, dosing schedule

Counterforce Health specializes in turning these denials into successful appeals by analyzing the specific denial reason and crafting evidence-backed responses that address payer criteria point-by-point.

When to Contact Texas Regulators

Contact the Texas Department of Insurance if:

  • Cigna violates appeal timelines (30 days standard, 72 hours expedited)
  • Step therapy exception isn't processed within 72 hours
  • IRO request is improperly denied or delayed
  • You need help understanding your appeal rights

TDI Consumer Helpline: 1-800-252-3439 IRO Information Line: 1-866-554-4926

Filing a Complaint

Use TDI's online complaint form and include:

  • Policy number and denial letters
  • Timeline of appeals filed
  • Documentation of missed deadlines or procedural violations

Cost Assistance Options

Bristol Myers Squibb Access Support:

  • Benefits verification and PA assistance
  • Copay cards for eligible commercially insured patients
  • Free drug program for qualifying uninsured patients
  • Phone: 1-888-POMALYST (1-888-766-2597)

Patient Advocacy Groups:

  • Leukemia & Lymphoma Society: Financial assistance and case management
  • Multiple Myeloma Research Foundation: Patient navigation services
  • CancerCare: Copay assistance and counseling
From our advocates: "We've seen Texas patients successfully overturn Pomalyst denials by focusing on the 'refractory to lenalidomide' requirement. The key is documenting progression within 60 days of last lenalidomide dose with lab values and imaging. When appeals include this timeline with NCCN citations, approval rates improve significantly."

FAQ

Q: How long does Cigna prior authorization take for Pomalyst in Texas? A: Standard review takes 7-14 business days. Expedited review (when medically urgent) takes 24-72 hours.

Q: What if Pomalyst isn't on my Cigna formulary? A: Request a formulary exception with medical necessity documentation. Texas law requires a clear exception process for non-formulary drugs.

Q: Can I get expedited appeal if my cancer is progressing? A: Yes. Have your oncologist document that treatment delays pose serious health risks and specifically request expedited review.

Q: Does step therapy apply if I failed lenalidomide in another state? A: No. Texas step therapy protections recognize prior therapy failures regardless of where they occurred. Provide documentation of previous treatment and failure.

Q: What's the success rate for IRO appeals in Texas? A: While specific Pomalyst data isn't available, Texas IRO decisions favor patients when clear medical necessity and guideline support are provided.

Q: How much does Pomalyst cost with Cigna coverage? A: Typically $150+ monthly copay on specialty tiers, but varies by plan. Manufacturer copay cards can reduce costs for eligible patients.

Q: Can Counterforce Health help with my Cigna appeal? A: Counterforce Health helps patients and clinicians create targeted appeals by analyzing denial letters and plan policies, then drafting evidence-backed responses that address specific payer criteria for drugs like Pomalyst.

Q: What if my employer plan is self-funded (ERISA)? A: Self-funded plans follow federal appeal rules instead of Texas IRO process, but similar internal appeal rights and medical necessity standards typically apply.

This guide provides educational information about insurance appeals and is not medical advice. Always consult your healthcare provider about treatment decisions. For personalized help with Texas insurance appeals, contact the Texas Department of Insurance consumer helpline at 1-800-252-3439.

Sources & Further Reading

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