By Counterforce Health Team in Pomalyst (pomalidomide) —

How to Get Pomalyst (pomalidomide) Covered by Humana in Pennsylvania: Complete PA Guide, Forms & Appeals

Answer Box: Getting Pomalyst Covered by Humana in Pennsylvania

For Pennsylvania residents with Humana Medicare Advantage or Part D: Pomalyst (pomalidomide) typically requires prior authorization. Submit Humana's "Request for Medicare Prescription Drug Coverage Determination" form with clinical documentation showing prior lenalidomide/proteasome inhibitor failure. First step today: Call Member Services (number on your card) to confirm your plan's formulary status and PA requirements. If denied, Pennsylvania's new Independent External Review Program (for commercial plans) or Medicare appeals process (for Medicare plans) can overturn ~50% of denials.

Table of Contents

I. Start Here: Verify Your Plan & Coverage

Before beginning any prior authorization, confirm your specific Humana plan type and Pomalyst's coverage status.

Plan Verification Steps

  1. Check your Humana ID card for plan type:
    • Medicare Advantage (MA-PD)
    • Medicare Part D standalone
    • Commercial/employer plan
    • Medicaid managed care
  2. Verify formulary status using Humana's drug list search tool
    • Enter "pomalidomide" or "Pomalyst"
    • Note tier level and restrictions (PA, step therapy, quantity limits)
  3. Confirm REMS requirements - Pomalyst requires enrollment in the PS-Pomalidomide/POMALYST REMS program for prescribers, pharmacies, and patients
Note: Different Humana products use different forms and processes. Medicare plans follow CMS rules, while commercial plans follow Pennsylvania state regulations.

II. Required Forms & Documentation

Primary Forms by Plan Type

For Humana Medicare Plans:

For Commercial Plans:

Medical Necessity Letter Requirements

Your oncologist must provide a supporting statement addressing:

Required Element What to Include CMS Standard Met
Diagnosis ICD-10 code for multiple myeloma, disease stage Medical necessity baseline
Prior Therapies Dates, duration, response to lenalidomide, proteasome inhibitors "Alternatives not as effective"
Treatment Failure Progression dates, intolerance, contraindications "Would cause adverse effects"
Clinical Rationale Why Pomalyst is appropriate next-line therapy Evidence-based necessity
Monitoring Plan CBC, REMS compliance, thrombosis prophylaxis Safety considerations

Documentation Checklist

Before submitting, gather:

  • Complete prior therapy timeline with dates
  • Oncology consultation notes
  • Pathology/cytogenetics reports
  • Recent lab values (CBC, comprehensive metabolic panel)
  • REMS enrollment confirmation
  • Current performance status assessment

III. Submission Portals & Electronic Options

Primary Electronic Submission

Availity Essentials is Humana's preferred electronic platform:

  • Sign in at Availity.com
  • Select "Pharmacy Prior Authorization"
  • Upload clinical attachments directly
  • Real-time status tracking available

CenterWell Specialty Pharmacy Portal

For specialty drug coordination:

  • E-prescribe directly to CenterWell Specialty Pharmacy
  • Use CenterWell provider portal for PA status
  • Coordinate benefits investigation and financial assistance
Tip: Electronic submission through Availity typically processes faster than fax/mail and provides immediate confirmation of receipt.

IV. Fax, Mail & Phone Contacts

Medicare Plans Contact Information

Prior Authorization Fax: 877-486-2621 (verify with current form)

Coverage Determinations Phone: Use Member Services number on your ID card

Provider Services: Call number on back of patient's card for PA support

Mailing Addresses

Addresses vary by specific plan. Check your current coverage determination form for:

  • Humana Medicare PA Review
  • Regional processing centers
  • Expedited vs. standard review addresses
Important: Always use the most current contact information from your plan-specific forms, as these can change quarterly.

V. Specialty Pharmacy Coordination

CenterWell Specialty Pharmacy Setup

Humana typically requires specialty medications like Pomalyst to be dispensed through CenterWell Specialty Pharmacy:

  1. Prescriber enrollment - Register with CenterWell provider portal
  2. Patient enrollment - Complete specialty pharmacy intake
  3. Benefits verification - CenterWell coordinates PA and copay assistance
  4. REMS compliance - Handles pomalidomide safety program requirements

Transfer Process

If currently using another specialty pharmacy:

  • CenterWell can coordinate prescription transfers
  • Maintain therapy continuity during transition
  • No gap in treatment when properly coordinated

VI. Support Phone Lines & Case Management

Member Support Contacts

Primary Contact: Member Services number on your Humana ID card

  • Benefits and coverage questions
  • PA status inquiries
  • Appeals assistance
  • Network provider referrals

Case Management Access:

  • Request through Member Services
  • Available for complex conditions like multiple myeloma
  • Helps coordinate care across specialties
  • Assists with medication management

Provider Support Lines

Provider Services: Number on patient's ID card

  • Eligibility verification
  • PA submission assistance
  • Claims status
  • Clinical review coordination

Pharmacy Support: Available through provider portal for:

  • Formulary alternatives
  • PA requirements
  • Step therapy exceptions
  • Quantity limit appeals

VII. Appeals Process for Pennsylvania

Medicare Plans (Federal Process)

For Humana Medicare Advantage/Part D denials:

  1. Internal Appeal (Redetermination)
    • Timeline: 65 days from denial date
    • Submit to address on denial letter
    • Include additional clinical evidence
  2. Independent Review Entity (IRE)
    • Automatic if internal appeal denied
    • Medicare-contracted third party
    • Binding decision on plan

Commercial Plans (Pennsylvania External Review)

Pennsylvania residents with Humana commercial plans can use the state's Independent External Review Program:

Eligibility Requirements:

  • Complete Humana's internal appeals process first
  • Receive Final Adverse Benefit Determination letter
  • File within 4 months of final denial

Pennsylvania External Review Success Rate: Approximately 50% of appeals are overturned in favor of patients

Contact Information:

  • Phone: 1-877-881-6388 (Pennsylvania Insurance Department)
  • Online: Submit through PA.gov external review portal
  • Timeline: 45 days for standard review, 72 hours for expedited

When to Request Expedited Review

Request expedited processing if:

  • Delay could seriously jeopardize health
  • Disease progression risk is imminent
  • Standard timeline would compromise treatment efficacy
From our advocates: In complex oncology cases, we've seen success when families compile a comprehensive timeline showing all prior treatments, exact progression dates, and specific contraindications to alternatives. This level of detail helps both internal reviewers and external review organizations understand why the requested medication is truly the only appropriate option.

VIII. Staying Current with Updates

Regular Check Points

Quarterly: Review Humana formulary updates

  • Coverage tier changes
  • New restrictions or requirements
  • Generic alternatives

Annually: Verify contact information and forms

  • PA submission processes may change
  • New electronic tools and portals
  • Updated appeal procedures

As Needed: Monitor for:

  • REMS program updates
  • FDA label changes
  • New clinical guidelines affecting coverage

Reliable Update Sources

  • Humana provider portal for policy changes
  • Pennsylvania Insurance Department for regulatory updates
  • Counterforce Health platform for coverage intelligence and appeals support

FAQ: Common Questions

How long does Humana PA approval take in Pennsylvania? Standard Medicare Part D prior authorizations: 72 hours. Commercial plans: typically 15 business days. Expedited reviews: 24-72 hours depending on plan type.

What if Pomalyst isn't on my Humana formulary? Submit a formulary exception request using the coverage determination form. Include medical necessity letter explaining why covered alternatives aren't appropriate.

Can I get expedited approval for urgent cases? Yes. Mark requests as expedited if standard processing could jeopardize health. Include physician attestation of urgency.

Does step therapy apply if I've already failed lenalidomide? Document all prior therapy failures with dates and outcomes. This should satisfy step therapy requirements, but may need formal exception request.

What financial assistance is available? Bristol Myers Squibb offers patient assistance programs including copay cards and free drug programs for eligible patients.

How do I appeal a denial in Pennsylvania? For Medicare plans: use federal Medicare appeals process. For commercial plans: complete Humana internal appeals first, then file with Pennsylvania's Independent External Review Program within 4 months.

What documentation strengthens my appeal? Include: complete treatment timeline, oncology consultation notes, current labs, performance status, specific contraindications to alternatives, and citations to clinical guidelines supporting pomalidomide use.

Can my doctor request a peer-to-peer review? Yes. Contact Provider Services to request clinical review with Humana's medical director. This can resolve denials without formal appeals.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance denials by creating targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements. For complex cases like pomalidomide appeals, Counterforce Health provides the clinical evidence, procedural expertise, and payer-specific workflows needed to turn denials into approvals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and verify current insurance requirements with your plan. Coverage policies and procedures change frequently; confirm all details with official sources before submitting requests.

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