By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (Pomalidomide) Covered by Cigna in New Jersey: Timeline, Appeals, and Required Forms

Answer Box: Getting Pomalyst Covered by Cigna in New Jersey

Cigna requires prior authorization for Pomalyst (pomalidomide) with specific documentation: proof of ≥2 prior therapies including lenalidomide and a proteasome inhibitor, disease progression within 60 days, and REMS program enrollment. Timeline: PA decisions within 1-2 business days after complete submission. First step: Have your oncologist gather treatment history and submit via Express Scripts portal or fax. If denied, you have 180 days to appeal internally, then 4 months for New Jersey's external review (IHCAP).

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Pre-Submission Preparation (Days 0-2)
  4. Submission to Initial Review (Days 1-5)
  5. Common Denial Reasons & Solutions
  6. Appeals Process in New Jersey
  7. REMS Program Requirements
  8. Timeline Visual
  9. Clinician Corner: Medical Necessity Documentation
  10. Costs & Patient Support
  11. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Pomalyst prescriptions Cigna PA Policy
Age Requirement Patient must be ≥18 years old Cigna Coverage Criteria
Prior Therapies Must have received lenalidomide + proteasome inhibitor FDA Label & Cigna Policy
Disease Progression Within 60 days of last therapy Clinical Documentation Required
Combination Therapy Must be used with dexamethasone Cigna Oncology Guidelines
REMS Enrollment Required before dispensing PS-Pomalidomide REMS
Appeals Deadline 180 days for internal, 4 months for external New Jersey Insurance Law

Step-by-Step: Fastest Path to Approval

1. Verify REMS Enrollment (Day 0)

Who: Prescriber
Action: Enroll at PS-Pomalidomide REMS or call 1-888-423-5436
Timeline: Same day for electronic enrollment

2. Gather Prior Therapy Documentation (Days 0-1)

Who: Clinical team
Documents needed:

  • Treatment timeline showing lenalidomide use and failure
  • Proteasome inhibitor (bortezomib, carfilzomib, etc.) history
  • Progression dates within 60 days of last therapy
  • Current multiple myeloma diagnosis with staging

3. Submit Prior Authorization (Day 1-2)

Who: Prescriber
Method: Express Scripts ePA portal or MyAccredoPatients.com
Include: Complete clinical rationale, ICD-10 codes, dosing plan with dexamethasone

4. Track Status (Days 2-3)

Timeline: Cigna/Express Scripts responds within 2 business days of complete submission
Monitor via: Provider portal or patient myCigna account

5. If Additional Information Requested (Days 3-5)

Response time: Submit within 5 business days to avoid delays
Common requests: Lab values, imaging, detailed progression notes

Pre-Submission Preparation (Days 0-2)

Essential Documentation Checklist

  • Insurance verification: Active Cigna coverage, member ID, group number
  • Diagnosis confirmation: Multiple myeloma with appropriate ICD-10 coding
  • Prior therapy timeline:
    • Lenalidomide (Revlimid) start/stop dates and reason for discontinuation
    • Proteasome inhibitor history (bortezomib, carfilzomib, ixazomib)
    • Disease progression documentation within 60 days
  • REMS enrollment: Prescriber certification complete
  • Combination therapy plan: Dexamethasone dosing schedule
  • Lab values: Recent CBC, comprehensive metabolic panel, performance status
Tip: Compile a "Pomalyst PA packet" with all documents in one folder. This speeds resubmission if additional information is requested.

Submission to Initial Review (Days 1-5)

New Jersey Timing Requirements

Under New Jersey's 2025 prior authorization regulations, Cigna must respond within:

  • Standard requests: 2 business days
  • Urgent requests: 1 business day

What Reviewers Check First

  1. Formulary status: Pomalyst tier placement and restrictions
  2. Medical necessity: Alignment with FDA-approved indications
  3. Prior therapy requirements: Evidence of lenalidomide + PI failure
  4. REMS compliance: Prescriber and patient enrollment verification
  5. Dosing appropriateness: 4mg daily, days 1-21 of 28-day cycle with dexamethasone

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Insufficient prior therapy documentation Submit detailed treatment timeline with dates, doses, and reasons for discontinuation. Include pharmacy records if available.
REMS enrollment incomplete Complete prescriber certification at PS-Pomalidomide REMS. Provide enrollment confirmation number.
Non-specialist prescriber Have hematologist/oncologist co-sign or transfer prescription. Include specialty credentials.
Missing combination therapy Clarify dexamethasone dosing plan (typically 40mg weekly). Submit complete regimen protocol.
Progression timeline unclear Provide imaging reports, lab values, or clinical notes documenting disease progression within 60 days of last therapy.

Appeals Process in New Jersey

Internal Appeals (First Level)

Filing deadline: 180 days from denial
Decision timeline:

  • Standard: 72 hours
  • Expedited: 24 hours

How to file:

  1. Submit via myCigna portal or mail to address on denial letter
  2. Include denial letter, supporting clinical documentation, prescriber letter
  3. Request expedited review if delay would harm patient health

External Review (IHCAP)

If internal appeal is denied, New Jersey's Independent Health Care Appeals Program (IHCAP) provides independent medical review.

Filing deadline: 4 months after final Cigna denial
Process: Administered by Maximus Federal Services
Timeline: 45 days for standard review, 48 hours for expedited
Cost: Free to patients

Note: IHCAP decisions are binding on insurers. If overturned, Cigna must cover the treatment.

REMS Program Requirements

Pomalyst is only available through the PS-Pomalidomide REMS program due to embryo-fetal toxicity risks.

Prescriber Requirements

Patient Requirements (varies by category)

  • Females of reproductive potential: Monthly surveys
  • Adult females not of reproductive potential: Surveys every 6 months
  • Males: Contraception counseling required

Pharmacy Requirements

  • REMS-certified specialty pharmacies only
  • Typically Accredo or other Express Scripts specialty locations

Timeline Visual

Day 0-1: REMS enrollment + documentation gathering
Day 1-2: PA submission via portal/fax
Day 2-3: Initial review (Cigna responds within 2 business days)
Day 3-5: Additional info requests (if needed)
Day 5-7: Final determination

If Denied:
Day 8-188: Internal appeal window (180 days)
Day 189-309: External review window (4 months from final denial)

Clinician Corner: Medical Necessity Documentation

Essential Elements for PA Letter

  1. Patient demographics: Age, diagnosis, staging, performance status
  2. Prior therapy history:
    • Lenalidomide: dates, doses, response, reason for discontinuation
    • Proteasome inhibitor: specific agent, duration, efficacy, toxicity
    • Other relevant treatments and outcomes
  3. Disease progression: Timeline, objective evidence (imaging, labs, clinical)
  4. Treatment rationale: Why Pomalyst is appropriate now
  5. Dosing plan: 4mg daily days 1-21/28 with dexamethasone 40mg weekly
  6. Monitoring plan: CBC, metabolic panel, toxicity assessments

Key Guidelines to Reference

When patients and clinicians need expert help navigating complex insurance denials, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to craft point-by-point rebuttals aligned with payer-specific requirements, helping secure coverage for medications like Pomalyst through data-driven appeal strategies.

Costs & Patient Support

Manufacturer Support (Bristol Myers Squibb)

  • BMS Access Support: Benefits verification, PA assistance, copay programs
  • Patient assistance: Free drug program for eligible uninsured/underinsured patients
  • Contact: 1-800-861-0048

Retail Pricing Context

  • Average wholesale price: ~$23,400 for 21-capsule pack (one cycle)
  • Medicare negotiation: Pomalyst included in 2025 Medicare price negotiation list (new prices effective 2027)

Additional Resources

  • Cancer Financial Assistance Coalition
  • Patient Advocate Foundation
  • Leukemia & Lymphoma Society copay assistance

FAQ

Q: How long does Cigna prior authorization take for Pomalyst in New Jersey?
A: Cigna/Express Scripts typically responds within 2 business days of receiving complete documentation. Urgent requests are processed within 1 business day per New Jersey regulations.

Q: What if Pomalyst isn't on my Cigna formulary?
A: You can request a formulary exception through the standard PA process. Include clinical rationale for why formulary alternatives aren't appropriate for your specific case.

Q: Can I get an expedited appeal if my treatment is delayed?
A: Yes. If delay would seriously jeopardize your health, request expedited review. Cigna must respond within 24 hours for urgent appeals, and IHCAP within 48 hours for expedited external reviews.

Q: Do I need a specialist to prescribe Pomalyst?
A: While not explicitly required by Cigna, most approvals come from hematologists/oncologists. REMS enrollment is required for all prescribers regardless of specialty.

Q: What counts as "disease progression within 60 days"?
A: Objective evidence like rising paraproteins, new lesions on imaging, increased bone marrow plasma cells, or clinical deterioration documented within 60 days of stopping your last therapy.

Q: Can I appeal if I live in New Jersey but have coverage from another state?
A: If your Cigna plan is regulated by New Jersey (typically employer plans based in NJ), you can use IHCAP. Self-funded employer plans follow federal ERISA rules instead.

When to Escalate

If you're experiencing delays or unfair denials, contact:

  • New Jersey Department of Banking and Insurance: 1-800-446-7467
  • IHCAP Hotline: 1-888-393-1062
  • Cigna Member Services: 1-800-882-4462

For complex cases requiring expert appeal assistance, Counterforce Health helps patients and clinicians build compelling, evidence-based appeals that address specific payer requirements and improve approval rates.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific medical situation and treatment options. Insurance coverage decisions are made by your plan based on your individual circumstances and policy terms.

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