By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (Pomalidomide) Covered by Humana in New York: Appeals Guide and State Protections

Answer Box: Getting Pomalyst (Pomalidomide) Covered by Humana in New York

Fastest path to approval: Submit a formulary exception request with your oncologist's supporting statement showing medical necessity and prior therapy failures (lenalidomide + proteasome inhibitor). Humana must respond within 72 hours. If denied, you have 65 days to appeal and can request New York's external review through the Department of Financial Services within 4 months. Start today: Contact Humana Member Services at 1-800-457-4708 to initiate the formulary exception process.

Table of Contents

  1. Why New York State Rules Matter for Humana Coverage
  2. Turnaround Standards and Decision Timelines
  3. Step Therapy Protections in New York
  4. Continuity of Care During Coverage Transitions
  5. External Review and State Appeals Process
  6. Practical Scripts for Humana Requests
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons and How to Fix Them
  9. When to Escalate: State Resources
  10. Frequently Asked Questions

Why New York State Rules Matter for Humana Coverage

New York's insurance regulations provide additional protections beyond federal Medicare requirements, especially important for Humana Medicare Advantage members seeking coverage for specialty drugs like Pomalyst (pomalidomide). The state's comprehensive appeal laws and step therapy protections can strengthen your case when Humana initially denies coverage.

For multiple myeloma patients, New York's external appeal process through the Department of Financial Services offers an independent review when Humana determines Pomalyst is "not medically necessary" or experimental. This state-level protection has successfully overturned many specialty drug denials, particularly in oncology cases where standard treatments have failed.

Line-of-business considerations: Humana Medicare Advantage plans follow both federal Medicare Part D rules and New York state regulations. However, if you have an employer-sponsored Humana plan governed by ERISA, some state protections may not apply—though the federal appeals process still provides coverage pathways.

Turnaround Standards and Decision Timelines

Understanding New York's specific timeline requirements helps you hold Humana accountable and know when to escalate:

Formulary Exception Requests

  • Standard decisions: 72 hours from receipt of prescriber's supporting statement
  • Expedited decisions: 24 hours for urgent drug requests when health is at serious risk
  • Appeal deadline: 65 days from denial notice to file your first-level appeal

New York Step Therapy Override Timeline

Starting January 1, 2026, New York's step therapy law requires health plans to respond within:

  • Emergency situations: 72 hours
  • Non-emergency requests: 3 business days (or 15 days from initial request, whichever is earlier)
Tip: If Humana doesn't respond within these timeframes, follow up immediately and document the delay—it may strengthen your appeal.

Step Therapy Protections in New York

New York's step therapy regulations, effective for policies renewed after January 1, 2026, provide specific grounds for overriding requirements that you try cheaper alternatives before Pomalyst:

Medical Exception Criteria

Your oncologist can request a step therapy override if:

  • Required drugs are contraindicated or will likely cause adverse reactions
  • You've already tried the required drug within the past 365 days with Humana coverage
  • The required drug is expected to be ineffective based on your medical history
  • You're a newly enrolled member (to prevent repeating step therapy from previous plans)

Documentation That Helps

When requesting a step therapy exception, include:

  • Prior therapy timeline: Dates of lenalidomide and proteasome inhibitor treatment
  • Progression documentation: Evidence of disease progression within 60 days of last therapy
  • Contraindication notes: Any adverse effects or medical reasons other drugs won't work
  • Treatment goals: Specific clinical outcomes expected with Pomalyst therapy

Continuity of Care During Coverage Transitions

New York provides strong protections for cancer patients experiencing insurance disruptions. If you're currently on Pomalyst and face a coverage change:

Active Treatment Protections

  • 90-day transitional period: Minimum coverage continuation required by state and federal law
  • Extended coverage: For active cancer treatment, coverage continues until treatment completion and clinical stability
  • Proposed Continuity of Cancer Care Act: Would require insurers to maintain coverage for the full course of planned treatment during provider contract disputes
Note: These protections apply regardless of whether you're switching plans or your oncologist's contract with Humana changes.

External Review and State Appeals Process

When Humana's internal appeals process fails, New York's external review offers an independent path to coverage:

When You're Eligible

  • After receiving a "final adverse determination" from Humana's appeal process
  • For denials based on medical necessity, experimental/investigational status, or formulary restrictions
  • Must file within 4 months of Humana's final denial

How to File External Review

  1. Complete the application: New York State External Appeal Application
  2. Submit required documents:
    • Humana's initial denial and final adverse determination
    • Physician attestation for specialty drug appeals
    • Supporting medical records and literature
  3. File your request:
    • Mail: NY Department of Financial Services, 99 Washington Avenue, Box 177, Albany, NY 12210
    • Fax: (800) 332-2729
    • For expedited appeals: Call 888-990-3991 when faxing

Decision Timeline

  • Standard external appeals: 30 days
  • Expedited appeals: 72 hours for standard cases, 24 hours for urgent drug denials

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals. Their platform helps patients and providers navigate complex appeal processes like New York's external review system, ensuring all required documentation and clinical evidence is properly submitted.

Practical Scripts for Humana Requests

Patient Phone Script for Formulary Exception

"Hello, I need to request a formulary exception for Pomalyst, generic name pomalidomide, for multiple myeloma treatment. My oncologist will provide a supporting statement showing I've failed lenalidomide and a proteasome inhibitor as required by your policy. Under New York law, you have 72 hours to make this decision. Can you start this request and give me a reference number?"

Clinic Staff Script for Medical Necessity

"I'm calling to request a peer-to-peer review for pomalidomide coverage denial. The patient has documented progression within 60 days of completing lenalidomide and bortezomib therapy, meeting your medical policy criteria. We can provide the treatment timeline and progression notes. When can we schedule the peer-to-peer with your medical director?"

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization Pre-approval required Medical necessity letter, prior therapy records Humana Provider Portal
Non-Formulary Status Not on standard drug list Formulary exception request with prescriber statement Humana Medicare Formulary
Line of Therapy Must be 3rd+ line treatment Documentation of ≥2 prior therapies including lenalidomide + PI FDA Pomalyst Label
REMS Enrollment Risk evaluation program required Prescriber, pharmacy, and patient certification POMALYST REMS Program
Specialist Prescriber Oncologist or hematologist required Board certification verification Humana Medical Policy

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Key Documents
"Not medically necessary" Submit treatment timeline showing lenalidomide + PI failure Prior therapy records, progression notes, oncologist letter
"Non-formulary drug" File formulary exception with medical justification Prescriber supporting statement, alternative drug contraindications
"REMS not completed" Confirm all parties enrolled in POMALYST REMS program REMS enrollment certificates, pharmacy verification
"Insufficient prior therapy" Document specific drugs tried and failure/intolerance Medication history, adverse event reports, treatment dates
"Not prescribed by specialist" Verify oncologist credentials with Humana Board certification, NPI verification, specialty designation

When to Escalate: State Resources

New York Department of Financial Services

Community Health Advocates

Free assistance with insurance appeals and specialty drug access:

  • Helpline: (888) 614-5400 (Monday-Friday, 9 a.m.-4 p.m.)
  • Email: [email protected]
  • Services: Appeal filing, prior authorization help, external review guidance
From our advocates: "We've seen multiple myeloma patients successfully overturn Pomalyst denials by emphasizing the specific 60-day progression requirement in their medical necessity letters. The key is showing clear documentation of disease advancement despite prior therapies, not just that other treatments were tried."

Counterforce Health's platform can help streamline this documentation process by analyzing your specific denial reasons and generating targeted appeals that address Humana's exact policy requirements, potentially saving weeks in the approval process.

Frequently Asked Questions

How long does Humana prior authorization take for Pomalyst in New York? Humana must respond within 72 hours for formulary exception requests and 7 days for standard appeals. Expedited decisions are available within 24 hours for urgent cases.

What if Pomalyst is non-formulary on my Humana plan? You can request a formulary exception with your oncologist's supporting statement. If denied, you have 65 days to appeal and can request New York's external review within 4 months.

Can I request an expedited appeal for Pomalyst? Yes, if your oncologist attests that delaying treatment would seriously jeopardize your health. Expedited appeals receive decisions within 24-72 hours.

Does step therapy apply if I failed treatments outside New York? Under New York's 2026 step therapy law, if Humana covered the required drugs within the past 365 days, you qualify for an automatic override regardless of where treatment occurred.

How much does Pomalyst cost with Humana coverage? Costs vary by plan tier and coverage determination. Retail cash prices average $23,400 per cycle, but covered patients typically pay significantly less through copay assistance and plan benefits.

What happens if Humana denies my external appeal? New York's external review decisions are binding on Humana. If the external reviewer approves coverage, Humana must provide it and refund your appeal fee (maximum $25, waived for financial hardship).

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance plan directly for coverage determinations. For personalized assistance with Humana appeals in New York, contact Community Health Advocates at (888) 614-5400 or the New York Department of Financial Services consumer helpline.

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