How to Get Pomalyst (pomalidomide) Covered by Aetna (CVS Health) in Georgia: Complete Prior Authorization and Appeals Guide
Answer Box: Getting Pomalyst (pomalidomide) Covered by Aetna (CVS Health) in Georgia
Pomalyst requires prior authorization from Aetna (CVS Health) in Georgia. The fastest path: (1) Ensure prescriber and patient are enrolled in the POMALYST REMS program with authorization number, (2) Submit PA via Availity provider portal with documented lenalidomide + proteasome inhibitor failure, and (3) Use CVS Specialty pharmacy for dispensing. If denied, Georgia law gives you 60 days from final internal appeal to request external review through the Georgia Department of Insurance. Start with the REMS enrollment today.
Table of Contents
- Verify Your Plan and Find the Right Forms
- Required Forms and Documentation
- Submission Portals and Process
- CVS Specialty Pharmacy Enrollment
- Support Lines and Contacts
- Appeals Process in Georgia
- Common Denial Reasons and Solutions
- Cost Assistance Options
- When to Contact Georgia Regulators
- Frequently Asked Questions
1. Verify Your Plan and Find the Right Forms
Before starting, confirm you have an Aetna (CVS Health) plan that covers specialty medications in Georgia. Check your member ID card for:
- Plan type (commercial HMO/PPO, exchange, Medicare Advantage)
- Pharmacy benefit manager (typically CVS Caremark)
- Member services number
Key verification steps:
- Call the number on your ID card to confirm Pomalyst requires prior authorization
- Ask if you must use CVS Specialty pharmacy for dispensing
- Request the current specialty medication precertification form
Note: Aetna's 2024 precertification list confirms Pomalyst requires PA across most products.
2. Required Forms and Documentation
Core Requirements for Aetna (CVS Health) Pomalyst PA
Clinical Documentation Checklist:
- Diagnosis: Multiple myeloma with ICD-10 code (C90.0x) plus pathology reports
- Prior therapy timeline: Documented failure/intolerance of both lenalidomide (Revlimid) AND a proteasome inhibitor
- REMS enrollment: Patient and prescriber certification in POMALYST/PS-Pomalidomide REMS program
- Prescriber: Oncologist or hematologist (specialist requirement)
- Recent labs: SPEP, UPEP, CBC, CMP within 30 days
- Medical necessity letter: Detailed rationale from prescribing oncologist
Medical Necessity Letter Template
Your oncologist should address:
- Patient's diagnosis and disease progression despite prior therapies
- Prior treatment failures: Specific dates, doses, and reasons for discontinuation of lenalidomide and proteasome inhibitor
- Clinical rationale: Why Pomalyst is medically necessary based on FDA labeling and NCCN guidelines
- REMS compliance: Confirmation of enrollment and ongoing monitoring plan
Clinician Corner: Include progression dates within 60 days of last therapy per FDA indication. Reference specific NCCN guideline sections supporting pomalidomide use in relapsed/refractory multiple myeloma.
3. Submission Portals and Process
Aetna Provider Portal Submission
Primary method: Submit via Availity provider portal using Novologix for specialty medications.
Step-by-step process:
- Log into Availity with Aetna-contracted provider credentials
- Navigate to Authorizations/Precertification → Pharmacy/Specialty
- Complete all Pomalyst-specific questions matching your documentation
- Upload supporting files (clinic notes, labs, REMS confirmation)
- Submit and track reference number
Alternative submission:
- Fax: Use current Aetna specialty medication precertification form
- Check form for specific fax number (varies by product)
Georgia-Specific Timing
According to Aetna's 2024 Georgia PA statistics, average decision time is 4.8 days for commercial plans. Submit at least 1-2 weeks before planned treatment start.
4. CVS Specialty Pharmacy Enrollment
Most Aetna (CVS Health) plans require Pomalyst to be filled through CVS Specialty pharmacy. This requires separate enrollment beyond PA approval.
Enrollment Process
For prescribers:
- Complete CVS Specialty Pomalyst/Revlimid/Thalomid enrollment form
- Include REMS authorization number on prescription
- Fax to: 1-800-323-2445
- Authorize CVS to handle PA submissions on your behalf
For patients:
- CVS Specialty will contact you to verify demographics and shipping address
- Complete clinical onboarding with CareTeam
- Set up online account for refill management
Tip: CVS Specialty coordinates REMS compliance, so ensure your prescriber includes the REMS authorization number on the enrollment form.
5. Support Lines and Contacts
Key Phone Numbers
| Contact Type | Number | Purpose |
|---|---|---|
| CVS Specialty (members) | 1-800-237-2767 | Prescription status, delivery, refills |
| Aetna Member Services | Number on ID card | Benefits, coverage questions |
| Aetna Provider Services | 1-800-238-6279 | PA status, peer-to-peer requests |
| BMS Access Support | 1-800-861-0048 | REMS enrollment, copay assistance |
What to Ask When You Call
For members calling Aetna:
- "Is Pomalyst covered on my plan and what's my copay?"
- "Do I need to use CVS Specialty pharmacy?"
- "What's the status of my prior authorization?"
For providers requesting peer-to-peer:
- "I need a peer-to-peer review for a Pomalyst PA denial"
- Have patient ID, denial reason, and clinical summary ready
6. Appeals Process in Georgia
Internal Appeal Timeline
| Level | Deadline to File | Decision Timeline | How to Submit |
|---|---|---|---|
| Internal Appeal | 180 days from denial | 30 days standard, 72 hours expedited | Aetna member portal or written request |
| External Review | 60 days from final internal denial | 30 business days standard, 72 hours expedited | Georgia DOI application |
Georgia External Review Process
After exhausting Aetna's internal appeals, you have the right to independent external review through the Georgia Department of Insurance.
Required documents:
- Georgia DOI independent review application form
- Copy of Aetna's final internal appeal denial
- All supporting medical records and physician letters
- Expedited certification (if urgent)
Contact for application: Email [email protected] or call Georgia DOI Consumer Services at 1-800-656-2298.
Important: The 60-day deadline is strict. Miss it and you lose the right to external review in Georgia.
7. Common Denial Reasons and Solutions
| Denial Reason | Solution | Required Documentation |
|---|---|---|
| Missing prior therapy | Document lenalidomide + PI failure | Treatment timeline with dates, responses, discontinuation reasons |
| REMS not completed | Complete enrollment | REMS authorization number, prescriber/patient certification |
| Not medically necessary | Strengthen clinical rationale | Updated physician letter with guideline references |
| Non-specialist prescriber | Transfer care or consultation | Oncologist/hematologist prescription and notes |
Sample Appeal Language
"Patient has documented progression of multiple myeloma within 60 days of last therapy, meeting FDA criteria for pomalidomide. Prior therapies included lenalidomide (failed after 8 months due to progression) and bortezomib (discontinued due to peripheral neuropathy). Per NCCN guidelines, pomalidomide with dexamethasone is appropriate third-line therapy."
8. Cost Assistance Options
Manufacturer Support
BMS Access Support provides:
- Benefits investigation and PA support
- Copay assistance (up to $25,000/year for eligible patients)
- Free drug program for uninsured/underinsured
- Contact: 1-800-861-0048
Additional Resources
- Patient Access Network Foundation: Grants for multiple myeloma patients
- HealthWell Foundation: Disease-specific copay assistance
- Georgia cancer assistance programs: Contact Georgia Cancer Info at 1-800-ACS-2345
9. When to Contact Georgia Regulators
Contact the Georgia Department of Insurance if:
- Aetna doesn't respond to appeals within required timeframes
- You believe the denial violates Georgia insurance law
- You need help with the external review process
Georgia DOI Consumer Services:
- Phone: 1-800-656-2298
- Online complaint form: Available on oci.georgia.gov
- Email: [email protected]
The Georgia DOI can informally contact insurers about delayed responses and ensure your external review is processed correctly.
10. Frequently Asked Questions
Q: How long does Aetna PA take in Georgia? A: Average 4.8 days per Aetna's 2024 Georgia statistics. Expedited reviews can be completed within 24-72 hours for urgent cases.
Q: What if Pomalyst is non-formulary on my plan? A: Request a formulary exception with documented medical necessity. Include evidence that formulary alternatives have failed or are contraindicated.
Q: Can I use a different specialty pharmacy? A: Most Aetna (CVS Health) plans require CVS Specialty for Pomalyst. Check your specific plan's pharmacy network requirements.
Q: What counts as "prior therapy failure"? A: Disease progression, inadequate response, or intolerance requiring discontinuation. Include specific dates and clinical outcomes in your documentation.
Q: Does step therapy apply if I used these drugs in another state? A: Yes, prior therapy history from any location counts. Provide complete treatment records regardless of where care was received.
Q: How do I expedite an appeal? A: Request expedited review if delay would seriously jeopardize health. Include physician certification of urgency and specific clinical risks.
About Counterforce Health
Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. The platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address specific payer criteria. For complex cases like Pomalyst coverage, Counterforce Health identifies the exact denial basis and drafts point-by-point rebuttals using FDA labeling, peer-reviewed studies, and specialty guidelines.
When appeals require detailed clinical documentation and payer-specific workflows—like Aetna's REMS requirements and Georgia's external review process—Counterforce Health provides the strategic approach needed to maximize approval chances while meeting all procedural requirements.
Sources & Further Reading
- Aetna 2024 Precertification List
- Aetna Georgia PA Statistics 2024
- CVS Specialty Enrollment Forms
- Georgia DOI Independent Review Process
- BMS Access Support
- FDA Pomalyst Prescribing Information
Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes can change. Always verify current requirements with your insurer and consult healthcare professionals for medical decisions. For additional assistance with insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.
Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.