By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (pomalidomide) Covered by Cigna in Washington: Complete Appeals Guide with Forms and Timelines

Quick Answer: To get Pomalyst (pomalidomide) covered by Cigna in Washington, you need prior authorization proving you've failed lenalidomide and a proteasome inhibitor, are 18+, and will use it with dexamethasone. Submit through Cigna's provider portal with complete treatment history. If denied, you have 180 days to appeal internally, then request external review through Washington's IRO system. Start by gathering your prior therapy records and contacting your oncologist to initiate the PA request today.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization Required for all Pomalyst prescriptions Completed PA form through provider portal Cigna Policy
Age Requirement Must be 18 years or older Birth date verification Cigna Policy
Prior Therapy Failed lenalidomide + proteasome inhibitor Treatment timeline with progression dates Cigna Policy
Combination Therapy Must use with dexamethasone Prescription for both medications FDA Label
REMS Enrollment All parties must be certified Provider, patient, pharmacy registration REMS Program
Appeal Deadline 180 days from denial Written appeal submission Washington State Law

Step-by-Step: Fastest Path to Approval

1. Gather Your Treatment History (Patient/Caregiver)

  • Collect records of all prior multiple myeloma treatments
  • Document dates of lenalidomide (Revlimid) and proteasome inhibitor (like bortezomib/Velcade) use
  • Note progression dates and reasons for stopping each treatment
  • Timeline: 1-2 days to collect records

2. Confirm REMS Program Eligibility (Oncologist)

  • Verify prescriber is enrolled in the POMALYST REMS program
  • Complete patient enrollment forms
  • Schedule required pregnancy testing if applicable
  • Timeline: 3-5 business days for REMS processing

3. Submit Prior Authorization Request (Oncologist's Office)

  • Complete Cigna's PA form through the provider portal
  • Include comprehensive treatment history showing lenalidomide and proteasome inhibitor failure
  • Attach oncology notes documenting disease progression
  • Timeline: Cigna responds within 5 business days per their policy

4. Follow Up on Authorization (Patient)

  • Call Cigna member services to confirm receipt and processing status
  • Request expedited review if medically urgent
  • Timeline: Check status after 3 business days

5. If Approved: Coordinate Specialty Pharmacy (All Parties)

  • Work with Express Scripts/Accredo for dispensing
  • Confirm REMS compliance before first shipment
  • Timeline: 2-3 business days for specialty pharmacy setup

6. If Denied: Initiate Internal Appeal (Patient/Prescriber)

  • Request detailed denial reason from Cigna
  • Gather additional supporting evidence
  • Submit written appeal within 180 days
  • Timeline: Internal appeal decision within 30 days

7. External Review if Needed (Patient)

Clinician Corner: When drafting the medical necessity letter, emphasize that Pomalyst is FDA-approved specifically for patients who have received at least two prior therapies including lenalidomide and a proteasome inhibitor. Reference the NCCN Guidelines for Multiple Myeloma and include specific dates of disease progression documented through lab values, imaging, or clinical assessments.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Prior therapy requirements not met" Submit detailed treatment timeline Pharmacy records, infusion logs, progress notes showing lenalidomide and PI use
"Patient under 18 years old" Verify birth date in medical record Copy of ID or medical record with correct birth date
"Not prescribed with dexamethasone" Update prescription to include combination New prescription showing both Pomalyst and dexamethasone
"REMS program not completed" Complete all REMS requirements REMS enrollment confirmation from BMS Patient Safety
"Insufficient medical necessity" Provide comprehensive clinical rationale Oncology consultation notes, imaging showing progression, lab values
"Non-specialist prescriber" Transfer prescription to oncologist Prescription from board-certified hematologist/oncologist

Appeals Process for Washington Residents

Washington state provides robust appeal rights for insurance denials. Here's your roadmap:

Internal Appeals with Cigna

  • First Level: Submit written appeal within 180 days of denial
  • Required: Include all medical records, treatment history, and clinical justification
  • Timeline: Cigna must respond within 30 days
  • Contact: Submit through Cigna member portal or mail to address on denial letter

External Review Through Washington State

If Cigna upholds the denial, you can request an independent review:

  • Deadline: 120 days from final internal denial (verify current timeframe with Washington Insurance Commissioner)
  • Process: Washington assigns an Independent Review Organization (IRO) with relevant medical expertise
  • Timeline: Standard decision within 45 days; expedited review within 72 hours if urgent
  • Cost: Free to the patient
  • Binding: IRO decision is final and binding on Cigna
Note: Washington's external review process is particularly effective for specialty medications like Pomalyst because the state assigns reviewers with oncology expertise who understand complex treatment protocols.

From our advocates: We've seen multiple myeloma patients in Washington successfully overturn Pomalyst denials by providing a detailed timeline showing exactly when they progressed on lenalidomide and their proteasome inhibitor. The key was including specific lab values and imaging dates that clearly documented treatment failure. This composite experience shows how thorough documentation can make the difference in complex oncology appeals.

REMS Program Requirements

The POMALYST REMS program is mandatory due to severe birth defect risks. All three parties must be certified:

Prescriber Requirements

  • Complete enrollment form and certification training
  • Counsel patients on risks and contraception requirements
  • Conduct mandatory pregnancy testing for women of reproductive age
  • Complete confidential survey for each prescription to receive authorization number

Patient Requirements

  • Sign Patient-Physician Agreement Form
  • Complete monthly surveys (women of reproductive age) or every 6 months (others)
  • Use two forms of reliable contraception if applicable
  • Understand risks of sharing medication or donating blood

Pharmacy Requirements

  • Specialty pharmacy certification through REMS program
  • Verify patient and prescriber enrollment before dispensing
  • Dispense only with valid authorization number

Contact REMS Support: 1-888-423-5436 for enrollment assistance

Cost-Saving Options

Pomalyst's retail cost can exceed $23,000 per cycle, but several programs can help:

Bristol Myers Squibb Access Support

  • Patient Assistance Program: Free medication for eligible uninsured/underinsured patients
  • Copay Card: Up to $25,000 annual savings for commercially insured patients
  • Benefits Investigation: Free insurance verification and PA support
  • Contact: 1-800-861-0048 or visit BMS Access Support

Foundation Support

  • Leukemia & Lymphoma Society: Copay assistance for blood cancer patients
  • CancerCare: Financial assistance and case management
  • Patient Advocate Foundation: Copay relief program

Washington State Programs

  • Apple Health (Medicaid): May cover Pomalyst for eligible low-income residents
  • Washington Prescription Drug Program: State assistance for Medicare beneficiaries
Tip: Apply for manufacturer assistance programs early in the process. BMS Access Support can often resolve PA issues while simultaneously providing financial support.

When to Contact Washington State Regulators

Contact the Washington State Office of the Insurance Commissioner if:

  • Cigna doesn't respond to appeals within required timeframes
  • You need help navigating the external review process
  • You believe Cigna violated Washington insurance laws
  • You want to file a formal complaint

Consumer Hotline: 1-800-562-6900 Online Complaint Form: Available on the OIC website

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform helps patients and clinicians navigate complex prior authorization requirements for specialty medications like Pomalyst, ensuring appeals align with each payer's specific criteria and procedural requirements.

Frequently Asked Questions

How long does Cigna prior authorization take for Pomalyst in Washington? Cigna must respond within 5 business days per their policy. Expedited reviews for urgent cases may be processed faster.

What if Pomalyst isn't on my Cigna formulary? You can request a formulary exception with clinical justification. This requires demonstrating medical necessity and that formulary alternatives are inappropriate.

Can I get expedited review if I'm already on Pomalyst? Yes, if discontinuing treatment would seriously jeopardize your health, you can request expedited internal appeal and expedited external review in Washington.

Does Washington's external review cost anything? No, external review through Washington's IRO system is free to patients.

What happens if I move from Washington to another state? Your appeal rights will change based on your new state's laws. Contact your new state's insurance commissioner for guidance.

Can my oncologist request a peer-to-peer review with Cigna? Yes, most insurers including Cigna offer peer-to-peer reviews where your oncologist can discuss the case directly with a Cigna medical director.

How do I prove I failed lenalidomide and a proteasome inhibitor? Provide pharmacy records, infusion logs, and clinical notes showing treatment dates and documented disease progression or intolerance.

What if my employer plan is self-funded? Self-funded plans may not be subject to Washington state law. Contact the U.S. Department of Labor for ERISA plan appeals, though many employers voluntarily follow state external review processes.

For patients and clinicians navigating complex specialty drug approvals, Counterforce Health offers comprehensive support in preparing prior authorization requests and appeals that meet payer-specific requirements while incorporating the clinical evidence needed for approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan, and policies change frequently. Always consult your healthcare provider for medical decisions and contact your insurance company or the Washington State Office of the Insurance Commissioner for current coverage and appeal procedures.

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