By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (Pomalidomide) Covered by Cigna in Virginia: Prior Authorization, Appeals, and Cost-Saving Strategies

Answer Box: Getting Pomalyst (Pomalidomide) Covered by Cigna in Virginia

Eligibility: Cigna covers Pomalyst (pomalidomide) for multiple myeloma patients 18+ who've tried at least one prior antimyeloma therapy and are enrolled in the REMS program. Fastest approval path: Have your oncologist submit prior authorization through Cigna's provider portal with complete treatment history, REMS enrollment confirmation, and clinical documentation. First step today: Contact your oncologist to confirm REMS enrollment and gather documentation of prior therapies (lenalidomide, proteasome inhibitors) with progression dates. If denied, Virginia's external review process provides binding decisions within 45 days through the State Corporation Commission Bureau of Insurance.

Table of Contents

  1. What Drives Pomalyst Costs with Cigna
  2. Benefit Investigation: What to Ask Your Plan
  3. Assistance Options and Savings Programs
  4. Prior Authorization Requirements
  5. Appeals Process in Virginia
  6. Specialty Pharmacy Coordination
  7. Annual Renewal Planning
  8. Conversation Scripts
  9. FAQ

What Drives Pomalyst Costs with Cigna

Pomalyst (pomalidomide) typically costs around $23,400 for a 21-day supply at retail, making it one of the most expensive oral cancer medications. With Cigna, your out-of-pocket costs depend on several factors:

Formulary Tier Placement Pomalyst appears on Cigna's 2024 specialty formularies but requires prior authorization. It's typically placed in Tier 5 (specialty tier) with coinsurance ranging from 25-40% after deductible. For a $23,400 monthly supply, this could mean $5,850-$9,360 per month in patient responsibility.

Benefit Design Impact

  • Deductible: Most Cigna plans have separate specialty drug deductibles ($500-$2,500 annually)
  • Out-of-pocket maximum: Specialty drugs count toward your annual limit ($8,700-$9,450 for 2024 individual coverage)
  • Site of care: Cigna may require specialty pharmacy dispensing through Express Scripts/Accredo
From our advocates: We've seen patients reduce their Pomalyst costs from over $8,000 monthly to under $50 by combining manufacturer copay assistance with formulary exception requests. The key is addressing both coverage and cost-sharing simultaneously.

Benefit Investigation: What to Ask Your Plan

Before starting treatment, gather this essential information by calling Cigna member services at 1-800-244-6224:

Coverage Questions to Ask:

  • Is Pomalyst on my plan's formulary? What tier?
  • What's my specialty drug deductible and coinsurance percentage?
  • Is prior authorization required? What are the clinical criteria?
  • Must I use a specific specialty pharmacy?
  • Are there quantity limits per fill?
  • What's my annual out-of-pocket maximum for prescription drugs?

Information to Record:

  • Reference number for your call
  • Representative's name and direct callback number
  • Specific policy language about multiple myeloma treatments
  • Prior authorization form names and submission methods
  • Appeal deadlines and procedures

Assistance Options and Savings Programs

Bristol Myers Squibb Copay Assistance

The BMS Co-Pay Assistance Program can reduce costs to $0 per prescription for eligible commercial insurance patients:

Eligibility Requirements:

  • Commercial insurance (employer, individual, ACA marketplace plans)
  • Valid Pomalyst prescription
  • U.S. residency
  • Not eligible: Medicare, Medicaid, TRICARE, or other government programs

How to Apply:

  1. Visit bmscopay.com or call 1-800-861-0048
  2. Complete online enrollment with insurance and prescription details
  3. Receive savings card for pharmacy use
  4. Annual benefit caps apply—review current terms before enrolling

Foundation Grants

For patients with government insurance or those who exceed copay card limits:

  • Patient Access Network Foundation: Grants for multiple myeloma patients
  • Good Days: Chronic disease assistance programs
  • HealthWell Foundation: Cancer treatment support

BMS Access Support Program

Bristol Myers Squibb provides comprehensive support through their Access Support program:

  • Benefits verification and prior authorization assistance
  • Appeal support with clinical documentation
  • Free drug programs for eligible uninsured patients
  • Patient navigation services

Prior Authorization Requirements

Cigna requires prior authorization for all Pomalyst prescriptions. Based on their coverage criteria, approval requires:

Coverage at a Glance

Requirement What It Means Documentation Needed
Age 18+ Adult patients only Date of birth verification
Multiple myeloma diagnosis Confirmed diagnosis with staging Pathology reports, imaging
Prior therapy failure ≥1 antimyeloma regimen tried Treatment timeline with dates
REMS enrollment Patient and prescriber certified REMS confirmation documents
Oncologist prescriber Hematology/oncology specialist Prescriber credentials
Combination therapy Often with dexamethasone Treatment plan documentation

Step-by-Step: Fastest Path to Approval

  1. REMS Enrollment (Patient + Oncologist)
    • Call 1-888-423-5436 or visit POMALYST REMS program
    • Complete patient-physician agreement forms
    • For women: pregnancy testing and contraception counseling
    • Timeline: 1-3 business days
  2. Gather Treatment History (Oncologist)
    • Document all prior antimyeloma therapies with dates
    • Include lenalidomide (Revlimid) and proteasome inhibitor exposure
    • Note progression dates and reasons for discontinuation
    • Timeline: Same day if records are organized
  3. Submit Prior Authorization (Oncologist)
    • Use Cigna provider portal or fax completed forms
    • Include REMS enrollment confirmation
    • Attach clinical notes supporting medical necessity
    • Timeline: Submit within 1-2 business days
  4. Cigna Review Process
    • Standard review: 5 business days
    • Urgent review: 72 hours if health would be jeopardized
    • Decision notification to prescriber and patient
  5. If Approved (Patient)
    • Prescription sent to Cigna-designated specialty pharmacy
    • Coordinate delivery and administration schedule
    • Set up copay assistance if eligible
  6. If Denied (Patient + Oncologist)
    • Review denial letter for specific reasons
    • Gather additional documentation addressing concerns
    • File internal appeal within 180 days

Appeals Process in Virginia

When Cigna denies Pomalyst coverage, Virginia provides robust appeal rights through multiple levels:

Internal Appeals with Cigna

First-Level Appeal:

  • Deadline: 180 days from denial notice
  • Method: Cigna member portal, phone, or written request
  • Timeline: Decision within 30 days (72 hours if urgent)
  • Required: Denial letter, additional clinical evidence, prescriber statement

Second-Level Appeal:

  • Automatic: If first appeal is denied
  • Timeline: 30 days for decision
  • Review: Independent medical professionals

Virginia External Review

After exhausting Cigna's internal appeals, Virginia's State Corporation Commission Bureau of Insurance provides binding external review:

Filing Requirements:

Submission Methods:

  • Email: [email protected]
  • Fax: (804) 371-9915
  • Mail: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218

Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours
  • Decision is binding on Cigna
Note: Virginia allows expedited external review for cancer treatment denials without exhausting internal appeals in certain urgent circumstances.

Specialty Pharmacy Coordination

Cigna typically requires Pomalyst dispensing through Accredo, their designated specialty pharmacy. This coordination involves:

REMS Compliance Requirements:

  • Accredo verifies patient and prescriber REMS enrollment before each fill
  • Pregnancy testing documentation (for women of reproductive age)
  • Patient counseling on safe handling and side effects
  • Limited 21-day supplies to ensure ongoing compliance

Patient Coordination Steps:

  1. Oncologist sends prescription to Accredo
  2. Accredo contacts patient for insurance verification
  3. Patient provides copay assistance card information
  4. Accredo coordinates delivery schedule
  5. Patient receives medication with handling instructions

Troubleshooting Common Issues:

  • REMS delays: Ensure all parties have current certifications
  • Insurance rejections: Verify prior authorization approval status
  • Shipping problems: Accredo provides temperature-controlled delivery
  • Refill timing: Plan for REMS compliance verification with each cycle

Annual Renewal Planning

Plan ahead for these annual changes that could affect Pomalyst coverage:

January Planning Checklist:

  • Review new formulary for tier placement changes
  • Confirm prior authorization renewals (typically required annually)
  • Update REMS enrollment if expired
  • Reassess copay assistance program eligibility
  • Budget for potential deductible restart

Mid-Year Monitoring:

  • Track spending toward out-of-pocket maximum
  • Watch for formulary updates (rare but possible)
  • Maintain communication with specialty pharmacy
  • Document any new side effects or treatment responses

Open Enrollment Preparation:

  • Compare Pomalyst coverage across available Cigna plans
  • Calculate total annual costs including premiums and copays
  • Consider supplemental coverage if available
  • Consult with benefits advisor about optimal plan selection

Conversation Scripts

Calling Cigna Member Services

"Hi, I'm calling about prior authorization for Pomalyst, generic name pomalidomide, for multiple myeloma treatment. I need to understand my plan's coverage requirements and costs. Can you tell me:

  • Is this medication on my formulary and what tier?
  • What prior authorization forms does my doctor need to submit?
  • What will my out-of-pocket cost be after approval?
  • Can you give me a reference number for this call?"

Requesting Peer-to-Peer Review (For Clinicians)

"I'm requesting a peer-to-peer review for my patient's denied Pomalyst prior authorization. This patient has relapsed/refractory multiple myeloma with documented progression on lenalidomide and bortezomib. Pomalyst is FDA-approved and guideline-recommended for this clinical scenario. When can I schedule the peer-to-peer discussion with your medical director?"

FAQ

How long does Cigna prior authorization take for Pomalyst in Virginia? Standard review takes 5 business days. Urgent requests are reviewed within 72 hours if your doctor certifies that delay would jeopardize your health.

What if Pomalyst is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification. Your oncologist must demonstrate that preferred alternatives are ineffective or inappropriate for your case.

Can I request an expedited appeal with Cigna? Yes, expedited appeals are available when delay would seriously harm your health. Your doctor must certify the urgency, and decisions are made within 72 hours.

Does Virginia's external review cost anything? No, Virginia provides free external review through the State Corporation Commission. There are no fees for patients.

What happens if I move from Virginia while on Pomalyst? Contact Cigna immediately to understand coverage changes. Some plans have national networks, while others may require plan changes that could affect prior authorizations.

How do I know if my REMS enrollment is current? Contact the POMALYST REMS program at 1-888-423-5436. Both patients and prescribers must maintain active enrollment for continued dispensing.

Getting Pomalyst covered by Cigna in Virginia requires careful coordination between you, your oncologist, and the insurance company. The key is thorough preparation with REMS compliance, complete documentation of prior therapies, and understanding your appeal rights. Counterforce Health helps patients and clinicians navigate complex prior authorization requirements by turning insurance denials into targeted, evidence-backed appeals that align with payer-specific criteria.

For additional assistance with your Pomalyst coverage, Virginia residents can contact the State Corporation Commission's Consumer Services at 1-877-310-6560 for guidance on insurance issues and appeal processes.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for personalized guidance. Coverage policies and procedures may change; verify current requirements with official sources.

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