By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (pomalidomide) Covered by Aetna CVS Health in New Jersey: Complete Coding, Appeals, and Authorization Guide

Answer Box: Getting Pomalyst (pomalidomide) Covered by Aetna CVS Health in New Jersey

Pomalyst requires prior authorization from Aetna CVS Health and strict REMS compliance. Key steps: 1) Ensure proper ICD-10 coding (C90.00 for active multiple myeloma), 2) Document prior lenalidomide and proteasome inhibitor failure, 3) Submit through CVS Specialty Pharmacy with complete clinical records. If denied, you have 180 days for internal appeals, then external review through New Jersey's IHCAP program via Maximus. Success rates for specialty drug appeals approach 50% with strong documentation. Start today: Contact your oncologist to begin prior authorization paperwork and verify REMS enrollment.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit Paths

Pomalyst (pomalidomide) is an oral immunomodulatory drug that can be covered under either your medical or pharmacy benefit, depending on your specific Aetna CVS Health plan structure.

Pharmacy Benefit Path (Most Common)

  • Dispensed through CVS Specialty Pharmacy
  • Requires prior authorization through CVS Caremark
  • Subject to specialty drug copays and quantity limits
  • REMS program compliance mandatory

Medical Benefit Path (Less Common)

  • Billed using HCPCS code J8999
  • May apply to certain buy-and-bill scenarios
  • Still requires prior authorization
  • REMS compliance still applies
Note: Most Aetna CVS Health plans route Pomalyst through the specialty pharmacy benefit due to its oral formulation and REMS requirements.

ICD-10 Mapping for Multiple Myeloma

Accurate ICD-10 coding is critical for Pomalyst approval. The primary codes for multiple myeloma are:

ICD-10 Code Description When to Use
C90.00 Multiple myeloma, not having achieved remission Active disease requiring treatment
C90.01 Multiple myeloma in complete remission Disease monitoring, maintenance therapy

Documentation Requirements for C90.00:

  • Evidence of active disease (M-protein levels, bone marrow biopsy results)
  • CRAB criteria documentation (Calcium elevation, Renal dysfunction, Anemia, Bone lesions)
  • Prior treatment history with specific agents and outcomes
  • Progression dates and objective measures

Supporting Documentation Words: Your oncologist's notes should include phrases like "relapsed/refractory multiple myeloma," "progression after lenalidomide," "failed proteasome inhibitor therapy," and specific biomarker results to support medical necessity.

Product Coding: HCPCS, NDC, and Units

HCPCS Coding

  • Primary code: J8999 ("Prescription drug, oral, chemotherapeutic, not otherwise specified")
  • Billed per 1 mg unit
  • No specific J-code exists for pomalidomide

NDC Numbers (11-digit format required) Common Pomalyst NDCs:

  • 4 mg capsules: 59572-105-01
  • 3 mg capsules: 59572-120-01
  • 2 mg capsules: 59572-115-01
  • 1 mg capsules: 59572-110-01

Unit Calculations For a typical 4 mg daily dose (21 days per 28-day cycle):

  • Total monthly units: 84 mg (21 capsules × 4 mg each)
  • Bill as: J8999 × 84 units

Modifiers

  • Add UD modifier if purchased under 340B Drug Pricing Program
  • No JW/JZ modifiers apply (oral capsules, not injectable)

Clean Prior Authorization Request

A complete prior authorization request to Aetna CVS Health should include:

Required Clinical Information:

  1. Diagnosis: ICD-10 code C90.00 with supporting lab values
  2. Prior Therapy Documentation:
    • Lenalidomide treatment dates, doses, duration
    • Proteasome inhibitor history (bortezomib, carfilzomib, etc.)
    • Reason for discontinuation (progression, intolerance)
  3. Proposed Regimen: Pomalyst 4 mg daily, days 1-21 of 28-day cycles with dexamethasone
  4. REMS Compliance: Confirmation of provider and patient enrollment

Sample Request Structure:

Patient: [Name], DOB: [Date]
Diagnosis: Multiple myeloma, not in remission (C90.00)
Prior Therapies: 
- Lenalidomide 25mg daily × 18 cycles (Jan 2022-Jun 2023), discontinued for progression
- Bortezomib 1.3 mg/m² × 8 cycles (Jul 2023-Feb 2024), discontinued for peripheral neuropathy
Requested: Pomalyst 4mg daily, days 1-21/28 with dexamethasone 40mg weekly
REMS Status: Provider and patient enrolled, pregnancy testing current

Common Coding Pitfalls

Unit Conversion Errors

  • Billing per capsule instead of per mg
  • Incorrect cycle calculations (21-day vs. 28-day cycles)
  • Missing fractional doses for dose reductions

Mismatched Codes

  • Using wrong ICD-10 for disease status (C90.01 for active disease)
  • Incorrect NDC for actual strength dispensed
  • Missing modifier for 340B purchases

Missing Documentation

  • Incomplete prior therapy timeline
  • Missing progression dates
  • Absent REMS enrollment confirmation

Aetna CVS Health Verification

Before submitting your request, verify current requirements:

Check Current Formulary Status

Prior Authorization Portal Submit requests through:

  • Availity provider portal for electronic submission
  • Fax: Check current provider manual for updated number
  • Phone: 1-888-632-3862 (commercial plans)

New Jersey Specific Considerations New Jersey law provides step therapy exemptions for stage IV metastatic cancer, which includes multiple myeloma. Reference this in your authorization request if applicable.

Appeals Process in New Jersey

If your initial prior authorization is denied, New Jersey offers a robust appeals process.

Internal Appeals with Aetna CVS Health

Level 1 Appeal:

  • Deadline: 180 days from denial
  • Timeline: 30 days for standard, 72 hours for expedited
  • Submit: Written appeal with additional clinical documentation

Level 2 Appeal:

  • Automatically triggered if Level 1 denied
  • New medical reviewers
  • Additional 30 days for decision

External Review Through IHCAP

After completing internal appeals, you can request external review through New Jersey's Independent Health Care Appeals Program (IHCAP), now administered by Maximus.

Key Details:

  • Deadline: 4 months after final internal denial
  • Cost: Free to patients
  • Success Rate: Approximately 50% for specialty drug appeals
  • Decision: Binding on Aetna CVS Health

How to File:

  1. Contact IHCAP at 1-888-393-1062
  2. Submit appeal through Maximus portal
  3. Include all denial letters and medical records
  4. Maximus reviews eligibility within 5 business days
From Our Advocates: We've seen multiple myeloma patients successfully overturn Pomalyst denials by emphasizing the specific FDA-approved indication for patients who've received "at least two prior therapies including lenalidomide and a proteasome inhibitor." Clear documentation of prior treatment failures with exact dates and progression evidence significantly strengthens these appeals.

Quick Audit Checklist

Before submitting your prior authorization or appeal:

Clinical Documentation:

  • ICD-10 code matches disease status (C90.00 for active disease)
  • Prior lenalidomide therapy documented with dates and reason for discontinuation
  • Proteasome inhibitor history included
  • Current disease markers and progression evidence attached

Coding Accuracy:

  • Correct NDC for prescribed strength
  • Proper unit calculations (mg, not capsules)
  • Appropriate modifiers applied if applicable
  • HCPCS code J8999 used for medical benefit billing

REMS Compliance:

  • Provider enrolled in Pomalyst REMS program
  • Patient counseling completed and documented
  • Pregnancy testing current (if applicable)
  • Dispensing pharmacy REMS-certified

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements.

FAQ

How long does Aetna CVS Health prior authorization take for Pomalyst? Standard prior authorization decisions typically take 30-45 days. Expedited reviews for urgent cases are completed within 72 hours. Submit requests at least 2 weeks before treatment start to avoid delays.

What if Pomalyst is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and providing evidence that preferred alternatives are inappropriate or ineffective for your specific case.

Can I request an expedited appeal in New Jersey? Yes, both Aetna's internal appeals and New Jersey's IHCAP program offer expedited review for cases where delays would cause serious harm to your health.

Does step therapy apply if I failed prior treatments outside New Jersey? Yes, prior treatment history from any location counts toward step therapy requirements. Ensure your oncologist documents all previous therapies with specific dates and outcomes.

What happens if my appeal is successful? If either Aetna's internal appeal or New Jersey's external review overturns the denial, Aetna must cover Pomalyst according to your plan's benefit structure and cannot re-deny for the same clinical indication.

How much will Pomalyst cost with Aetna CVS Health coverage? Costs vary by plan, but specialty drugs typically have higher copays. Check with CVS Caremark for your specific copay amount and investigate manufacturer copay assistance programs through Bristol Myers Squibb Access Support.

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 with your healthcare provider and insurance plan directly for specific coverage questions. For personalized assistance with complex prior authorization and appeal processes, Counterforce Health helps patients and clinicians navigate insurance denials with evidence-based appeal strategies tailored to each payer's specific requirements.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.