By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (Pomalidomide) Covered by Blue Cross Blue Shield in Georgia: Complete Prior Authorization Guide

Answer Box: Getting Pomalyst Covered by BCBS Georgia

Pomalyst (pomalidomide) requires prior authorization from Blue Cross Blue Shield Georgia (Anthem) and must be filled through their specialty pharmacy networks (CarelonRx or BioPlus). To get approved: 1) Your oncologist submits a PA request documenting prior lenalidomide and proteasome inhibitor failure, 2) Complete REMS enrollment with signed Patient-Physician Agreement, and 3) Fill at an approved specialty pharmacy. Start today: Call BCBS member services (number on your card) to confirm your specialty pharmacy network and ask your oncologist to begin the PA process via Availity portal.

Table of Contents

Is Pomalyst Covered by BCBS Georgia?

Yes, Pomalyst is covered by Blue Cross Blue Shield of Georgia (Anthem) plans, but it requires prior authorization and is typically placed on Tier 3 (specialty) of the formulary. Coverage applies to FDA-approved uses:

  • Multiple myeloma (with dexamethasone) after at least 2 prior therapies including lenalidomide and a proteasome inhibitor
  • Kaposi sarcoma in specific circumstances

Which BCBS Georgia Plans Cover Pomalyst:

  • Commercial employer plans (Essential, Traditional, Select)
  • Individual/family plans (ACA marketplace)
  • Medicare Advantage plans (with additional restrictions)
Note: Coverage details vary by your specific plan design. Always verify with member services before starting treatment.

Who Submits the Prior Authorization?

Your oncologist or hematologist must submit the prior authorization request. BCBS Georgia requires specialist prescribing for Pomalyst.

How to Check PA Status:

  1. Patients: Log into your Anthem member portal or call the member services number on your ID card
  2. Providers: Use the Availity portal or call the pharmacy help desk
  3. Timeline: Standard PA decisions within 7 calendar days of complete submission

How Long Does Approval Take?

Request Type Timeline How to Request
Standard PA 7 calendar days Availity portal, fax, or phone
Expedited PA 72 hours Call Clinical Pharmacy line with urgency documentation
Peer-to-peer review 24 hours to schedule Request through provider portal

What Counts as Urgent:

  • Disease progression requiring immediate treatment
  • Hospitalization risk
  • Serious adverse reactions to current therapy

What Documentation Is Required?

Coverage at a Glance

Requirement What It Means Where to Find It
Prior therapies Must have failed lenalidomide + proteasome inhibitor Treatment records, oncology notes
REMS enrollment Patient-Physician Agreement signed BMS REMS Patient Safety portal
Specialist prescriber Hematologist/oncologist required Provider NPI verification
Specialty pharmacy CarelonRx or BioPlus network only Anthem formulary list

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient)
    • Call BCBS member services to confirm your plan includes specialty pharmacy benefits
    • Ask which network applies: CarelonRx or BioPlus
  2. Complete REMS Enrollment (Provider + Patient)
    • Prescriber enrolls in PS-Pomalidomide REMS program
    • Patient signs Patient-Physician Agreement Form
    • Document pregnancy testing/contraception plan (if applicable)
  3. Gather Clinical Documentation (Provider)
    • Prior therapy timeline with dates and outcomes
    • Progression documentation (labs, imaging, bone marrow results)
    • Current disease status and treatment goals
  4. Submit PA Request (Provider)
    • Use Availity portal with complete clinical package
    • Include REMS authorization number
    • Reference NCCN Multiple Myeloma Guidelines
  5. Monitor Decision (Patient + Provider)
    • Track via provider portal or member portal
    • Prepare appeal documents if needed
  6. Fill at Specialty Pharmacy (Patient)
    • Transfer prescription to approved network pharmacy
    • Coordinate delivery and refill schedule
  7. Set Renewal Reminder (Patient)
    • Most approvals last 6-12 months
    • Schedule renewal 30 days before expiration

Understanding Your Costs

Typical Cost Structure:

  • Tier 3 specialty copay: Often $100-500+ per month depending on your plan
  • Coinsurance plans: You may pay 20-40% of the drug cost
  • Deductible: May apply before copay kicks in

Savings Options:

  • Bristol Myers Squibb Access Support: Copay assistance and free drug programs for eligible patients
  • State programs: Georgia has limited assistance; check with Georgians for a Healthy Future
  • Foundation grants: Patient advocacy organizations may offer financial assistance
Tip: Call BMS Access Support before your first fill to explore all available assistance programs.

Why Was My Request Denied?

Common Denial Reasons & Solutions

Denial Reason How to Fix It
Insufficient prior therapy documentation Submit detailed treatment timeline with progression dates and lab values
REMS requirements not met Complete all REMS enrollment steps and provide authorization number
Non-specialist prescriber Transfer prescription to hematologist/oncologist
Missing combination therapy plan Document planned use with dexamethasone
Step therapy not satisfied Provide evidence of lenalidomide and proteasome inhibitor failure

Appeals Process in Georgia

Internal Appeal (First Level):

  • Deadline: 60 days from denial notice
  • How: Submit via BCBS member portal or mail
  • Timeline: Decision within 30 days (7 days for urgent)

External Review (Independent):

  • Deadline: 60 days after internal appeal denial
  • How: Contact Georgia Department of Insurance at 1-800-656-2298
  • Cost: Free to consumers
  • Timeline: 30 business days (72 hours for urgent cases)

When to Request Expedited Appeals:

  • Immediate health risk from treatment delay
  • Disease progression requiring urgent intervention
  • Current therapy causing serious adverse effects
From our advocates: We've seen many successful Pomalyst appeals in Georgia when providers include a detailed timeline showing exactly when lenalidomide stopped working and how quickly the disease progressed. The key is painting a clear picture of medical necessity with specific dates and lab values.

When Do I Need to Renew?

Typical Renewal Schedule:

  • Initial approval: Usually 3-6 months
  • Ongoing renewals: 6-12 months with response documentation
  • Set reminders: 30 days before expiration

Renewal Requirements:

  • Treatment response documentation (labs, imaging)
  • Continued medical necessity
  • Updated REMS compliance
  • No unacceptable toxicity

Specialty Pharmacy Requirements

BCBS Georgia requires Pomalyst to be filled through designated specialty pharmacy networks:

Approved Networks:

  • CarelonRx Exclusive Network
  • BioPlus Exclusive Network

Why This Matters:

  • Prescriptions filled outside these networks are not covered
  • Your local pharmacy cannot fill Pomalyst even with a valid prescription
  • The specialty pharmacy coordinates with REMS requirements

How to Find Your Network Pharmacy:

  1. Check your formulary document
  2. Call BCBS pharmacy member services
  3. Use the Anthem provider portal pharmacy locator

Troubleshooting Common Issues

Portal Access Problems:

  • Clear browser cache and cookies
  • Try different browser or incognito mode
  • Call technical support during business hours

Missing Forms:

Prescription Transfer Issues:

  • Work with your oncologist's office to coordinate transfer
  • Provide specialty pharmacy with complete insurance information
  • Confirm REMS authorization is active before transfer

Frequently Asked Questions

How long does BCBS Georgia PA take for Pomalyst? Standard prior authorization decisions are made within 7 calendar days of receiving complete documentation. Expedited reviews can be completed within 72 hours for urgent cases.

What if Pomalyst is non-formulary on my plan? Even if non-formulary, you can request a formulary exception by documenting medical necessity and failure of preferred alternatives. Work with your oncologist to submit a detailed exception request.

Can I request an expedited appeal in Georgia? Yes, Georgia allows expedited external reviews for urgent medical situations. You can request this even while an internal appeal is pending if delay poses serious health risks.

Does step therapy apply if I failed treatments outside Georgia? Yes, prior therapy documentation from any state or healthcare system counts toward step therapy requirements, as long as you can provide complete treatment records.

What happens if my REMS enrollment expires? Your pharmacy cannot dispense Pomalyst without active REMS enrollment. Contact your prescriber immediately to renew enrollment and avoid treatment interruptions.

How do I find a specialty pharmacy in my area? Call the pharmacy member services number on your BCBS ID card or use the online pharmacy locator. They'll help you find an approved CarelonRx or BioPlus network pharmacy.

Can I appeal to someone other than BCBS? After exhausting internal appeals, you can request an external review through the Georgia Department of Insurance. This provides an independent medical review at no cost to you.

What if I can't afford my copay? Contact Bristol Myers Squibb Access Support for copay assistance programs. You may also be eligible for foundation grants or state assistance programs.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address the specific reasons for denial. We've helped thousands of patients access critical medications by providing the clinical documentation and procedural expertise needed to navigate complex prior authorization processes.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations may change. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions.

Need Help? Contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298 or visit oci.georgia.gov for assistance with insurance appeals and complaints.

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