How to Get Pomalyst (Pomalidomide) Covered by Humana in Michigan: Prior Authorization Guide & Appeal Templates
Answer Box: Getting Pomalyst (Pomalidomide) Covered by Humana in Michigan
Fastest path to approval: Submit prior authorization with documented failure of both lenalidomide and a proteasome inhibitor, plus oncologist letter confirming medical necessity. If denied, file internal appeal within 65 days, then request Michigan DIFS external review within 127 days. Start today: Call Humana at 866-461-7273 to request PA forms, or submit online via Availity.
Table of Contents
- Read the Denial: Decode Reason Codes
- Fixable Causes Before Appealing
- Prior Authorization Requirements
- First-Level Appeal Strategy
- Peer-to-Peer Call Preparation
- Michigan External Review Process
- Medical Necessity Letter Template
- Common Denial Reasons & Solutions
- Cost Assistance Programs
- Frequently Asked Questions
Read the Denial: Decode Reason Codes
When Humana denies Pomalyst (pomalidomide), the denial letter will specify the exact reason. Common codes include:
- Prior authorization required: You need approval before filling the prescription
- Step therapy not met: Must try other medications first (typically lenalidomide + proteasome inhibitor)
- Non-formulary drug: Pomalyst isn't on Humana's preferred drug list
- Quantity limits exceeded: Requesting more than the approved amount
- Not medically necessary: Clinical documentation doesn't support the request
Tip: Look for the denial date and your appeal deadline—you have 65 days from the denial notice to file an appeal with Humana.
Fixable Causes Before Appealing
Before starting a formal appeal, check if these quick fixes apply:
Missing Documentation
- Prior therapy records: Humana needs proof you've tried and failed lenalidomide and a proteasome inhibitor
- Oncologist prescription: Must be prescribed by or in consultation with a hematologist/oncologist
- ICD-10 codes: Ensure your diagnosis code for multiple myeloma is included (typically C90.00)
REMS Program Enrollment
Pomalyst requires enrollment in the PS-Pomalidomide/POMALYST REMS program. Your prescriber and pharmacy must be certified before Humana will approve coverage.
Coding Issues
Verify the correct NDC number and dosing schedule (typically 4mg daily, days 1-21 of 28-day cycles) are on the prescription.
Prior Authorization Requirements
Humana requires prior authorization for Pomalyst across all Medicare Advantage and Part D plans. Here's what you need:
Coverage Criteria Checklist
| Requirement | Details | Documentation Needed |
|---|---|---|
| Age | 18+ years old | Date of birth |
| Diagnosis | Confirmed multiple myeloma | Pathology reports, ICD-10 code |
| Prescriber | Oncologist or hematologist | Provider NPI and specialty |
| Prior therapies | Failed lenalidomide AND proteasome inhibitor | Treatment timeline with dates |
| Dosing | ≤4mg daily, days 1-21/28 | Prescription details |
| REMS enrollment | Provider and pharmacy certified | REMS confirmation |
How to Submit
Online: Availity portal (requires provider registration)
Fax: 888-447-3430
Phone: 866-461-7273 (Monday-Friday, 8 AM-11 PM Eastern)
Note: New Humana Medicare Advantage members get a 90-day grace period for ongoing treatments started before enrollment.
First-Level Appeal Strategy
If your prior authorization is denied, file an internal appeal immediately. You have 65 days from the denial date.
What to Include in Your Appeal
- Cover letter stating you're appealing the denial and want reconsideration
- Original denial notice (copy)
- Updated medical necessity letter from your oncologist
- Complete treatment history showing lenalidomide and proteasome inhibitor failures
- Recent lab results and imaging if applicable
- Clinical notes documenting disease progression
Appeal Submission Methods
Mail:
Humana Inc.
Appeals Department
P.O. Box 14079
Lexington, KY 40512-4079
Fax: Check your denial letter for the specific appeals fax number
Online: Through your Humana member portal
Peer-to-Peer Call Preparation
If the written appeal is denied, request a peer-to-peer review where your oncologist speaks directly with Humana's medical director.
Prep Checklist for Your Doctor
- Patient timeline: Diagnosis date, prior treatments, progression dates
- Clinical rationale: Why Pomalyst is medically necessary now
- Alternative failures: Specific reasons lenalidomide and proteasome inhibitors didn't work
- Treatment goals: Expected outcomes with Pomalyst therapy
- Guidelines: Reference NCCN or other professional guidelines supporting the decision
Key Talking Points
"This patient has relapsed/refractory multiple myeloma with documented progression within 60 days of their last therapy. They've failed both an immunomodulatory agent (lenalidomide) and a proteasome inhibitor, meeting FDA labeling criteria for Pomalyst."
Michigan External Review Process
If Humana upholds their denial after internal appeals, Michigan residents can request an independent external review through the Department of Insurance and Financial Services (DIFS).
Timeline and Process
- Deadline: 127 days after Humana's final denial
- Standard review: Decision within 60 days
- Expedited review: Decision within 72 hours (requires physician letter stating urgency)
- Cost: Free to Michigan residents
How to File
Online: Michigan.gov/DIFS external review portal
Phone: 877-999-6442 (Monday-Friday, 8 AM-5 PM)
Mail:
Michigan Department of Insurance and Financial Services
Office of General Counsel – Appeals Section
P.O. Box 30220
Lansing, MI 48909-7720
Required Documents
- Humana's final denial letter
- All medical records supporting your case
- Physician letter (for expedited review)
- Completed external review request form
Medical Necessity Letter Template
Your oncologist should include these elements in the medical necessity letter:
Essential Components
Patient Information
- Name, DOB, Humana member ID
- Diagnosis: Multiple myeloma with ICD-10 code
- Date of initial diagnosis
Treatment History
- Lenalidomide: dates used, duration, reason for discontinuation
- Proteasome inhibitor: specific drug, dates, reason for failure
- Other prior therapies and outcomes
Clinical Rationale
- Current disease status and symptoms
- Why Pomalyst is medically necessary
- Expected treatment outcomes
- Contraindications to formulary alternatives
Treatment Plan
- Pomalyst dosing: 4mg daily, days 1-21 of 28-day cycles
- Combination with dexamethasone if applicable
- Monitoring plan and supportive care
Sample Language
"[Patient name] is a [age]-year-old with relapsed/refractory multiple myeloma diagnosed on [date]. Despite treatment with lenalidomide for [duration] and [proteasome inhibitor] for [duration], the patient experienced disease progression. Per FDA labeling and NCCN guidelines, Pomalyst is indicated for patients who have received at least two prior therapies including lenalidomide and a proteasome inhibitor."
Common Denial Reasons & Solutions
| Denial Reason | Solution | Required Documentation |
|---|---|---|
| Step therapy not met | Provide timeline showing lenalidomide + PI failure | Treatment records with dates and outcomes |
| Non-specialist prescriber | Transfer care to oncologist/hematologist | Referral and specialist consultation notes |
| Incomplete REMS | Complete provider and pharmacy certification | REMS enrollment confirmation |
| Lack of combination therapy | Justify Pomalyst + dexamethasone regimen | Treatment protocol and clinical rationale |
| Insufficient prior therapy | Document ≥2 prior lines including required drugs | Complete treatment history with progression dates |
Cost Assistance Programs
Even with insurance coverage, Pomalyst can be expensive. These programs may help:
Bristol Myers Squibb Access Support
Phone: 1-800-861-0048
Services: Prior authorization assistance, appeals support, copay cards, patient assistance programs
Website: BMS Access Support
Eligibility Requirements
- Copay cards: Commercial insurance patients (not Medicare/Medicaid)
- Patient assistance: Income-based eligibility, typically <400% of federal poverty level
- Free drug programs: For uninsured patients meeting income criteria
Other Resources
- Leukemia & Lymphoma Society: Financial assistance for blood cancer patients
- CancerCare: Co-payment assistance and emergency financial aid
- Good Days: Copay assistance for chronic disease medications
Frequently Asked Questions
Q: How long does Humana prior authorization take for Pomalyst?
A: Standard PA decisions are typically made within 72 hours for urgent requests, up to 14 days for non-urgent requests.
Q: What if Pomalyst isn't on Humana's formulary?
A: You can request a formulary exception with medical necessity documentation. Your doctor must attest that formulary alternatives would be less effective or cause adverse effects.
Q: Can I get an expedited appeal in Michigan?
A: Yes, if your doctor states that waiting would seriously jeopardize your health. Michigan DIFS must decide expedited appeals within 72 hours.
Q: Do I need to try specific drugs before Pomalyst?
A: Yes, Humana requires documented failure of both lenalidomide (or another immunomodulatory agent) and a proteasome inhibitor.
Q: What if I'm dual-eligible (Medicare and Medicaid)?
A: You may have additional appeal rights through both Medicare and Michigan Medicaid systems. Contact your plan to understand which pathway applies.
Q: Can my doctor file the appeal for me?
A: Yes, your physician can file appeals on your behalf with written authorization.
From our advocates: We've seen Pomalyst approvals succeed when oncologists include a detailed timeline showing exactly when each prior therapy was tried, how long it was used, and the specific reason it failed (progression, intolerance, contraindication). The more precise the documentation, the stronger your case becomes.
When You Need Extra Support
Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating evidence-backed, payer-specific rebuttal letters. The platform analyzes denial letters and plan policies to identify the exact approval pathway, then drafts targeted appeals that address each denial reason with the right clinical evidence and procedural requirements.
If you're facing repeated denials or complex appeal requirements, specialized support can make the difference between paying out-of-pocket and getting your medication covered. Counterforce Health streamlines this process by ensuring your appeal meets Humana's specific requirements and includes all necessary documentation for Michigan's regulatory framework.
Sources & Further Reading
- Humana Prior Authorization Forms and Process
- Michigan DIFS External Review Process
- Pomalyst FDA Prescribing Information
- BMS Access Support Program
- CMS Medicare Part D Appeals Process
Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about your specific situation. Insurance coverage policies can change, so verify current requirements with Humana and Michigan DIFS before proceeding with appeals.
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