By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (pomalidomide) Covered by Aetna CVS Health in Pennsylvania: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Pomalyst Covered by Aetna CVS Health in Pennsylvania

Pomalyst (pomalidomide) requires prior authorization from Aetna CVS Health in Pennsylvania. Your fastest path to approval: (1) Ensure REMS program enrollment is complete, (2) Submit PA request with documented lenalidomide and proteasome inhibitor failure, and (3) Include oncologist attestation. If denied, Pennsylvania's external review program has a 50% success rate overturning denials. Start today: Call Bristol Myers Squibb Access Support at 1-888-423-5436 to begin REMS enrollment while your oncologist gathers prior therapy documentation.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before coverage Aetna Precertification List Aetna
REMS Enrollment Mandatory safety program PS-Pomalidomide REMS Bristol Myers Squibb
Prior Therapy Failure Lenalidomide + proteasome inhibitor Clinical documentation FDA Label
Prescriber Requirements Oncologist/hematologist preferred PA submission Aetna Policy
Appeal Deadline 180 days from denial Final adverse determination letter Aetna
External Review 4 months after final denial PA Insurance Department Pennsylvania DOI

Step-by-Step: Fastest Path to Approval

1. Begin REMS Enrollment (Patient & Prescriber)

Who: Patient and prescriber together
Timeline: 1-3 business days
Action: Call 1-888-423-5436 or visit PS-Pomalidomide REMS portal. Complete surveys, sign Patient-Physician Agreement Form.
Key Detail: Each prescription requires a new authorization number.

2. Gather Prior Therapy Documentation

Who: Clinic staff
Timeline: 2-5 business days
Action: Collect records showing lenalidomide failure and proteasome inhibitor failure (bortezomib, carfilzomib, or ixazomib).
Required: Start/stop dates, response status, progression evidence.

3. Submit Prior Authorization Request

Who: Prescriber
Timeline: Submit within 24-48 hours of REMS completion
Action: Use Availity provider portal or Aetna PA forms.
Include: REMS authorization number, clinical notes, prior therapy timeline.

4. Track Status and Respond to Requests

Who: Clinic staff
Timeline: Check within 48-72 hours
Action: Monitor portal for additional information requests. Respond within 24 hours to avoid delays.
Tip: Aetna typically decides within 30 days for standard requests.

5. If Denied: Request Peer-to-Peer Review

Who: Prescriber
Timeline: Within 48 hours of denial
Action: Call CVS Caremark Prior Authorization Department (number on denial letter).
Goal: Clinical discussion with Aetna medical director.

6. File Internal Appeal if Needed

Who: Patient or prescriber
Timeline: Within 180 days of denial
Action: Submit Aetna appeal form with additional clinical evidence.
Deadline: Aetna has 45 business days to decide.

7. Pennsylvania External Review (Final Step)

Who: Patient
Timeline: Within 4 months of final internal denial
Action: File with Pennsylvania Insurance Department.
Success Rate: Approximately 50% of denials overturned.

Understanding the REMS Requirement

Pomalyst is only available through the PS-Pomalidomide REMS program due to embryo-fetal toxicity risks. This FDA-mandated safety program affects every prescription.

Critical: Pomalyst will not be dispensed without completed REMS enrollment, even with insurance approval.

Prescriber Requirements:

  • Enroll at PS-Pomalidomide REMS portal
  • Complete confidential survey for each prescription
  • Obtain unique authorization number
  • Sign Patient-Physician Agreement Form

Patient Requirements:

  • Complete enrollment survey (different requirements for men vs. women of reproductive potential)
  • Sign Patient-Physician Agreement Form
  • Receive counseling from REMS-certified pharmacy

Timeline Impact: Allow 1-3 business days for REMS completion before insurance approval becomes effective.

Common Denial Reasons & How to Fix Them

Denial Reason Fix Strategy Required Documentation
"Prior therapy not documented" Submit detailed treatment timeline Clinical notes with start/stop dates, response assessment
"REMS not complete" Provide authorization number REMS confirmation, Patient-Physician Agreement Form
"Non-specialist prescriber" Transfer to oncologist or obtain consultation Oncology consultation note, specialist attestation
"Not medically necessary" Cite FDA indication and guidelines FDA label, NCCN guidelines, peer-reviewed studies
"Step therapy not met" Document lenalidomide + PI failure Lab reports showing progression, IMWG criteria documentation

Appeals Process for Aetna CVS Health in Pennsylvania

Internal Appeal (Required First Step)

  • Deadline: 180 days from denial date
  • Timeline: 45 business days for standard review, 72 hours for expedited
  • How to File: Aetna provider portal or mail completed appeal form
  • Required: Original denial letter, additional clinical evidence, prescriber attestation

Peer-to-Peer Review Option

Contact CVS Caremark Prior Authorization Department to request clinical discussion. This can occur before or during the formal appeal process.

Script for Clinic Staff:

"I'm calling to request a peer-to-peer review for [patient name], member ID [number], regarding the Pomalyst prior authorization denial. Dr. [name] would like to discuss the clinical necessity with your medical director."

External Review Through Pennsylvania

If internal appeal fails, Pennsylvania residents have access to independent review with strong patient success rates.

Pennsylvania's External Review Advantage

Pennsylvania launched its own external review program in January 2024, creating a patient-friendly alternative to federal processes.

Key Benefits:

  • 50% success rate for overturned denials in 2024
  • State oversight ensures thorough review
  • No cost to patients
  • Binding decisions on insurers

Eligibility: ACA-compliant plans (not Medicare or Medicaid)
Timeline: 45 days for standard review, 72 hours for expedited
How to Apply: Online portal is fastest

From Our Advocates: We've seen Pennsylvania's external review process work particularly well for specialty drug denials where patients have clear clinical documentation but insurers cite "experimental" or "not medically necessary" reasons. The independent medical reviewers tend to focus on FDA approval status and clinical guidelines rather than cost considerations.

Cost-Saving Programs

Bristol Myers Squibb Access Support

  • Benefits verification: Free insurance coverage check
  • Copay assistance: May reduce out-of-pocket costs for eligible patients
  • Free drug program: For uninsured or underinsured patients
  • Contact: 1-888-423-5436

Additional Resources

  • Patient Access Network Foundation: Grants for multiple myeloma patients
  • HealthWell Foundation: Copay assistance programs
  • Pennsylvania CHIP/Medicaid: Coverage for eligible low-income residents

When to Contact State Regulators

Contact the Pennsylvania Insurance Department if:

  • Aetna fails to meet appeal deadlines
  • You suspect bad faith denial practices
  • The insurer won't accept your external review decision

Pennsylvania Insurance Department Consumer Services: Available via pa.gov for guidance on appeals and complaints.

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in Pennsylvania?
Standard PA requests are typically decided within 24-72 hours when complete, with up to 30 days allowed by regulation. REMS enrollment adds 1-3 business days to the overall timeline.

What if Pomalyst is non-formulary on my Aetna plan?
Request a formulary exception with your PA submission. Include clinical rationale for why formulary alternatives (like lenalidomide) have failed or are inappropriate.

Can I request an expedited appeal if my condition is urgent?
Yes. Aetna processes expedited appeals within 72 hours when a physician certifies that delays would jeopardize health or recovery ability.

Does Pennsylvania's external review cost anything?
No. The state-run external review process is free to consumers and funded through insurer fees.

What happens if I start Pomalyst while appealing?
If you pay out-of-pocket during an appeal, Aetna must reimburse you if the appeal is successful. Keep all receipts and pharmacy documentation.

Can I switch to a different Aetna plan during open enrollment?
Yes, but Pomalyst will still require prior authorization on any new plan. Consider formulary coverage when comparing options.

How does the REMS program affect my pharmacy choice?
Pomalyst can only be dispensed by REMS-certified pharmacies, typically CVS Specialty or other designated specialty pharmacies in Aetna's network.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer-specific requirements, pulling appropriate clinical evidence and operational details that reduce back-and-forth with insurers.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage decisions vary by individual plan and circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For additional help with Pennsylvania insurance issues, contact the Pennsylvania Insurance Department Consumer Services.

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