By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (Pomalidomide) Covered by Cigna in North Carolina: Complete 2025 Guide with Forms and Appeal Scripts

Answer Box: Getting Pomalyst Covered by Cigna in North Carolina

Cigna covers Pomalyst (pomalidomide) for multiple myeloma with prior authorization after at least one prior regimen including lenalidomide and/or a proteasome inhibitor. Medicare Advantage plans list it as Tier 4 specialty; commercial plans require PA and often step therapy. If denied, use Cigna's internal appeals (180 days for commercial, 65 days for Medicare), then North Carolina's Smart NC external review within 4 months.

First step today: Call Cigna at the number on your card to confirm formulary status and request PA forms. Have your oncologist document prior therapies and progression dates.

Table of Contents

  1. Coverage Basics: Is Pomalyst Covered?
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Clinical Criteria and Step Therapy
  5. Costs and Coverage Tiers
  6. Denials and Appeals
  7. Renewals and Re-authorization
  8. Specialty Pharmacy Requirements
  9. Common Problems and Solutions
  10. Frequently Asked Questions

Coverage Basics: Is Pomalyst Covered?

Cigna Medicare Advantage Plans

Pomalyst (pomalidomide) is covered on Cigna's 2025 Medicare formularies including Enhanced, Standard, and Basic plans as a Tier 4 specialty drug. Coverage includes:

  • Prior authorization required (PA)
  • Quantity limits (typically 168 capsules per 28 days)
  • Limited availability (LA) at select specialty pharmacies
  • High-risk medication (HRM) designation requiring additional monitoring

Cigna Commercial Plans

Commercial employer-sponsored plans typically cover Pomalyst as a specialty tier medication with:

  • Prior authorization requirements
  • Step therapy protocols
  • Higher copays or coinsurance (20-50%)
  • Specialty pharmacy network restrictions
Note: Coverage varies by specific employer plan. Check your Summary of Benefits or call Cigna member services for exact details.

Prior Authorization Process

Who Submits the PA Request

Your oncologist or prescribing physician must submit the prior authorization request. Patients cannot submit PA requests directly, but you can help gather required documentation.

Required Documentation

According to Cigna's oncology PA policy, the following must be included:

Clinical Information:

  • Patient age (≥18 years required)
  • Multiple myeloma diagnosis with staging
  • Documentation of at least one prior myeloma regimen
  • Prior therapy timeline with dates and outcomes
  • Current disease status and treatment goals

Prior Therapy Documentation:

  • Lenalidomide-based regimens (dates, duration, response)
  • Proteasome inhibitor exposure (bortezomib, carfilzomib, ixazomib)
  • Reason for discontinuation (progression, toxicity, intolerance)
  • Imaging or lab results showing disease progression

How to Submit

For Medicare Advantage:

  • Call the prior authorization number on your ID card
  • Submit via Cigna provider portal
  • Fax completed forms to the number specified for your plan

For Commercial Plans:

  • Use Cigna's online provider portal
  • Call 1-855-242-4642 for PA requests
  • Fax to the prior authorization department (number on denial letter)

Timing and Urgency

Standard PA Timeline

  • Medicare Advantage: Up to 72 hours for standard requests
  • Commercial: Within 72 hours for pre-service requests
  • Expedited requests: Within 24 hours when delay could harm health

When to Request Expedited Review

Request urgent processing if:

  • Disease is rapidly progressing
  • Patient has limited treatment options remaining
  • Delay could compromise planned interventions (transplant, CAR-T therapy)
Tip: Have your oncologist explicitly state in writing that the case is urgent and explain the medical risks of delay.

Clinical Criteria and Step Therapy

Cigna's Requirements for Pomalyst

Based on Cigna's coverage policy:

Requirement Details Documentation Needed
Age ≥18 years Date of birth verification
Diagnosis Multiple myeloma Pathology report, staging
Prior Therapy At least one prior regimen Treatment timeline with dates
Line of Therapy Relapsed/refractory disease Progression documentation
Combination Usually with dexamethasone Planned regimen details

What Counts as Prior Therapy

Acceptable prior regimens include:

  • Lenalidomide-based combinations (Revlimid + dexamethasone ± other agents)
  • Proteasome inhibitor regimens (bortezomib, carfilzomib, ixazomib-based)
  • Monoclonal antibody combinations (daratumumab-based regimens)
  • Standard induction regimens prior to autologous transplant

Costs and Coverage Tiers

Medicare Advantage Cost-Sharing

For Tier 4 specialty drugs like Pomalyst:

  • Deductible phase: You pay full cost until plan deductible is met
  • Initial coverage: Typically 25-33% coinsurance
  • Coverage gap: Reduced coinsurance under Inflation Reduction Act
  • Catastrophic phase: $0 after $2,100 out-of-pocket in 2025

Commercial Plan Costs

  • Specialty tier copay: Often $100-500 per month
  • Coinsurance: Typically 20-50% of drug cost
  • Annual out-of-pocket maximum: Varies by plan (often $3,000-8,000)

Financial Assistance Options

  • Bristol Myers Squibb Access Support: Patient assistance programs and copay cards
  • Foundation grants: Leukemia & Lymphoma Society, Patient Advocate Foundation
  • Medicare Extra Help: Low-income subsidy reducing costs to $0-10.20

Denials and Appeals

Common Denial Reasons and Solutions

Denial Reason How to Fix Required Documentation
Missing prior therapy Document all previous treatments Pharmacy records, clinic notes
Step therapy not met Show progression on required agents Imaging, labs, progression notes
Non-specialist prescriber Transfer to oncologist/hematologist Specialist consultation
REMS not complete Enroll in POMALYST REMS program REMS enrollment confirmation
Not medically necessary Provide clinical guidelines support NCCN guidelines, peer-reviewed studies

Internal Appeals with Cigna

Commercial Plans:

  • Deadline: 180 days from denial date
  • Timeline: Decision within 30 days (72 hours if urgent)
  • Address: Use address on denial letter or submit via member portal

Medicare Advantage:

  • Deadline: 65 days from coverage determination
  • Timeline: 72 hours for standard, 24 hours for expedited
  • Method: Call, fax, mail, or online submission

North Carolina External Review

If Cigna upholds the denial after internal appeals, North Carolina residents can request external review through Smart NC.

Smart NC Process:

  1. Call Smart NC: 1-855-408-1212 (toll-free)
  2. Timeline: Request within 4 months of final Cigna denial
  3. Decision time: 45 days standard, 72 hours expedited
  4. Cost: Free to consumers
  5. Binding: IRO decision is binding on Cigna
From our advocates: We've seen multiple myeloma patients successfully overturn Cigna denials through Smart NC when they provided comprehensive documentation of prior therapy failures and current disease progression. The key is having your oncologist clearly explain why formulary alternatives are no longer appropriate for your specific case.

Renewals and Re-authorization

When to Renew

  • Initial approval: Typically granted for 6-12 months
  • Renewal timing: Submit 30 days before expiration
  • Required updates: Current disease status, treatment response, toxicity assessment

Documentation for Renewal

  • Recent imaging or lab results
  • Treatment response assessment
  • Toxicity monitoring results
  • Continued medical necessity justification

Specialty Pharmacy Requirements

REMS Program Enrollment

Pomalyst requires enrollment in the PS-Pomalidomide/POMALYST REMS program:

  • Prescriber certification in REMS program
  • Patient enrollment and signed agreement
  • Pregnancy testing for females of reproductive potential
  • Contraception requirements for all patients

Cigna Specialty Pharmacies

For Cigna members, Pomalyst is typically dispensed through:

  • Accredo Specialty Pharmacy (Cigna's preferred specialty pharmacy)
  • Other REMS-certified specialty pharmacies in network

Common Problems and Solutions

Portal Issues

  • Problem: Cigna portal down or forms not loading
  • Solution: Call member services or fax forms directly

Missing Documentation

  • Problem: PA denied for incomplete information
  • Solution: Request specific list of missing items and resubmit

REMS Delays

  • Problem: REMS enrollment holding up approval
  • Solution: Contact BMS Access Support for REMS assistance

Pharmacy Transfer Issues

  • Problem: Local pharmacy can't fill Pomalyst
  • Solution: Transfer to Cigna-approved specialty pharmacy

Frequently Asked Questions

Q: How long does Cigna PA take in North Carolina? A: Standard requests: 72 hours. Expedited requests when medically urgent: 24 hours.

Q: What if Pomalyst is non-formulary on my plan? A: Request a formulary exception with clinical justification showing why covered alternatives won't work.

Q: Can I request an expedited appeal? A: Yes, if delay could seriously harm your health. Your oncologist must document the urgency.

Q: Does step therapy apply if I failed treatments outside North Carolina? A: Yes, prior therapy documentation from any location counts toward step therapy requirements.

Q: What happens if I miss a renewal deadline? A: You may need to restart the PA process. Submit renewal requests 30 days early to avoid gaps.

Q: Can family members help with appeals? A: Yes, with proper authorization forms allowing them to speak with Cigna on your behalf.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful approvals through evidence-based appeals. Our platform analyzes denial letters, identifies specific policy requirements, and generates targeted appeals with the right clinical evidence and procedural compliance. We help patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes for specialty medications like Pomalyst.

Sources and Further Reading

This guide provides general information about insurance coverage and appeal processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with them to navigate insurance requirements. For personalized assistance with North Carolina insurance issues, contact Smart NC at 1-855-408-1212.

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