By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (pomalidomide) Covered by Humana in Georgia: Complete Prior Authorization Guide and Appeals Process

Answer Box: Quick Path to Pomalyst Coverage

Getting Pomalyst (pomalidomide) covered by Humana in Georgia requires prior authorization with step therapy documentation. You must show failure of lenalidomide (Revlimid) plus a proteasome inhibitor, enroll in the PS-Pomalidomide REMS program, and have your oncologist submit medical necessity documentation. First step today: Call your oncologist to gather prior therapy records and start REMS enrollment at bmsremspatientsafety.com. If denied, you have 65 days for Medicare Advantage appeals (federal process) or 60 days for Georgia external review (non-Medicare plans).

Table of Contents

Why Georgia State Rules Matter for Humana Coverage

Georgia's insurance laws create important protections for specialty drug coverage, though they interact differently depending on your specific Humana plan type. Medicare Advantage plans follow federal CMS rules, while fully-insured commercial Humana plans must comply with Georgia Department of Insurance regulations.

Plan Type Breakdown

Plan Type Regulatory Authority Key Protections
Humana Medicare Advantage Federal (CMS) 65-day appeal rights, IRE review for Part B drugs
Fully-Insured Commercial Georgia DOI 60-day external review, step therapy exceptions
Self-Funded Employer ERISA (limited state protections) Internal appeals primarily

Important: Georgia's external review process only applies to state-regulated plans, not Medicare Advantage. However, Georgia residents with MA plans still benefit from federal protections and can file complaints with the Georgia DOI for procedural violations.

Prior Authorization Requirements and Timelines

Coverage Requirements at a Glance

Requirement Details Documentation Needed
Step Therapy Must fail lenalidomide + proteasome inhibitor Treatment timeline, progression dates
Prior Therapies ≥2 previous multiple myeloma treatments Complete therapy history
Disease Status Progression ≤60 days from last therapy Recent scans, labs, oncologist notes
REMS Enrollment PS-Pomalidomide safety program Confirmation number from BMS
Prescriber Hematology/oncology specialist preferred Board certification documentation

Georgia Timeline Standards

For fully-insured plans in Georgia:

  • Prior Authorization Decision: 2 business days (standard), 24 hours (urgent)
  • Internal Appeals: 30 days (standard), 72 hours (expedited)
  • External Review Filing: 60 days from final internal denial

For Humana Medicare Advantage:

  • PA Decision: 30 days (standard), 72 hours (expedited)
  • Level 1 Appeal: 65 days to file, 7 days for decision
  • Level 2 IRE Review: Automatic if denied, 72 hours for urgent cases
Note: Georgia law requires automatic approval if insurers miss PA deadlines, but this protection doesn't apply to Medicare Advantage plans.

Step Therapy Protections in Georgia

Georgia provides medical exception criteria for step therapy requirements, which can help if you've already failed required medications or have contraindications.

Medical Exception Criteria

You can request a step therapy override if:

  • Prior failure outside the plan: You've already tried and failed lenalidomide or proteasome inhibitors under previous insurance
  • Contraindication exists: Medical reasons prevent use of required first-line drugs
  • Drug interaction concerns: Current medications create dangerous combinations
  • Allergy or intolerance: Documented adverse reactions to required medications

Documentation for Exceptions

Your oncologist should include:

  • Specific medical rationale: Why Pomalyst is medically necessary now
  • Prior therapy details: Dates, doses, duration, and reason for discontinuation
  • Clinical guidelines support: References to NCCN, ASH, or other oncology guidelines
  • Alternative consideration: Why other options are inappropriate

Continuity of Care During Transitions

Humana Transition Policies

New Medicare Advantage members get temporary coverage while PA is processed:

  • 30-day supply at retail pharmacies (multiple refills allowed during first 90 days)
  • 31-day supply for long-term care residents
  • Coverage continues while pursuing formulary exceptions

Commercial plan transitions in Georgia must provide:

  • 30-day emergency supply for ongoing specialty medications
  • Grace period for PA completion without interruption
  • Continuation of previously approved medications during plan changes
Tip: If you're switching to Humana mid-treatment, request transition coverage immediately and start the PA process on day one.

Appeals Process: Federal vs. State Options

For Humana Medicare Advantage Plans

Level 1 - Plan Reconsideration

  • Deadline: 65 days from denial notice
  • Decision time: 7 days standard, 72 hours expedited
  • How to file: Call 1-800-867-6601 or submit via MyHumana portal
  • Required: Denial letter, medical records, prescriber statement

Level 2 - Independent Review Entity (IRE)

  • Automatic: If Level 1 denied or missed deadline
  • Decision time: 7 days standard, 72 hours expedited
  • Focus: Medical necessity and coverage criteria compliance

For Georgia State-Regulated Plans

Internal Appeal

  • Deadline: 180 days from denial (or service date)
  • Decision time: 30 days standard, 72 hours urgent
  • Submit to: Humana appeals department with complete medical file

External Review

  • Deadline: 60 days from final internal denial
  • Process: File with Georgia DOI Consumer Services
  • Cost: Free to consumer
  • Decision: Binding on insurer if favorable

To request Georgia external review:

  1. Call 1-800-656-2298 (GA DOI Consumer Services)
  2. Submit application with all denial letters and medical records
  3. Include physician statement of medical necessity
  4. Request expedited review (72 hours) if urgent

Medical Necessity Documentation

Clinician Corner: Essential Letter Components

Patient Information

  • Multiple myeloma diagnosis with ICD-10 codes (C90.x)
  • Disease stage and prognostic factors
  • Performance status and treatment goals

Prior Therapy Documentation

  • Lenalidomide details: Dosing, duration, best response, progression date
  • Proteasome inhibitor history: Which agent, cycles completed, reason for discontinuation
  • Other treatments: Complete therapy timeline with dates and outcomes

Clinical Rationale

  • Why Pomalyst is appropriate now (FDA indication criteria met)
  • Expected benefits based on clinical trials
  • Monitoring plan for side effects and efficacy

Supporting Evidence

  • Recent imaging showing progression
  • Laboratory values (M-protein, free light chains)
  • REMS enrollment confirmation number

REMS Enrollment Process

Required for all Pomalyst prescriptions:

  1. Prescriber registration: Complete training at bmsremspatientsafety.com
  2. Patient enrollment: Contraception counseling and agreement
  3. Pharmacy certification: Dispense only through REMS-certified pharmacies
  4. Ongoing requirements: Monthly pregnancy tests for women of childbearing potential
Important: REMS enrollment typically takes 1-2 business days. Start this process immediately upon deciding to prescribe Pomalyst.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
REMS not complete Submit confirmation number REMS enrollment screenshot
Step therapy not met Provide prior failure documentation Treatment records with dates
Non-specialist prescriber Transfer to oncologist or get consultation Board certification, referral
Insufficient progression proof Submit recent imaging/labs Scans within 60 days, M-protein levels
Missing combination therapy Document dexamethasone plan Concurrent prescription or rationale

Sample Appeal Language

"Patient has relapsed/refractory multiple myeloma with progression within 60 days of last therapy, meeting FDA criteria for Pomalyst. Prior treatments include lenalidomide/dexamethasone (progressed after 8 cycles) and bortezomib-based therapy (discontinued for neuropathy). REMS enrollment complete (confirmation #[number]). Request expedited review given oncologic urgency."

Cost-Saving Resources

Bristol Myers Squibb Access Support

Patient assistance programs:

  • Copay assistance: Up to $25,000/year for eligible patients
  • Free drug program: For uninsured patients meeting income criteria
  • Benefits verification: PA support and appeals assistance
  • Contact: 1-800-861-0048 or BMS Access Support

Georgia-Specific Resources

Georgians for a Healthy Future

  • Consumer assistance with insurance appeals
  • Educational materials on patient rights
  • Referrals to legal aid for complex cases

Georgia Legal Services Program

  • Free legal help for low-income residents
  • Assistance with Medicaid and insurance appeals
  • Available in all 159 Georgia counties

When to Contact Regulators

Georgia Department of Insurance

File a complaint if Humana:

  • Misses PA decision deadlines
  • Fails to provide required transition coverage
  • Doesn't honor favorable external review decisions
  • Violates Georgia step therapy protections

Contact information:

  • Phone: 1-800-656-2298
  • Online: Consumer Complaint Form
  • Mail: 2 Martin Luther King Jr. Drive, Suite 716, Atlanta, GA 30334

For Medicare Advantage Issues

Contact 1-800-MEDICARE if:

  • Humana violates federal appeal timelines
  • IRE decisions are not implemented
  • Discrimination in coverage decisions
  • Procedural violations in PA process

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies coverage criteria gaps, and generates evidence-backed rebuttals that speak directly to payer policies. For complex cases like Pomalyst coverage, we help compile the right clinical documentation and regulatory citations to strengthen your appeal.

Frequently Asked Questions

How long does Humana prior authorization take for Pomalyst in Georgia? Standard PA decisions take 30 days for Medicare Advantage, 2 business days for Georgia commercial plans. Expedited reviews are available in 72 hours when medically urgent.

What if Pomalyst isn't on my Humana formulary? You can request a formulary exception with medical necessity documentation. Humana provides transition coverage during the first 90 days while exceptions are processed.

Can I appeal if I'm denied step therapy exception? Yes. Document why lenalidomide or proteasome inhibitors are inappropriate, contraindicated, or previously failed. Georgia law supports medical exceptions to step therapy.

Does Georgia external review apply to Medicare Advantage? No. Medicare Advantage appeals follow federal CMS rules through IRE review. However, you can file Georgia DOI complaints for procedural violations.

What counts as "progression within 60 days" for Pomalyst coverage? Recent imaging showing disease advancement, rising M-protein levels, or clinical deterioration documented within 60 days of your last myeloma therapy.

How do I get expedited review for urgent cases? Your oncologist must document that delay would seriously jeopardize your health. Include this statement in all PA and appeal submissions for 72-hour processing.

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For additional help with Georgia insurance appeals, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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