By Counterforce Health Team in Pomalyst (pomalidomide) —

The Requirements Checklist to Get Pomalyst (Pomalidomide) Covered by Aetna (CVS Health) in North Carolina

Answer Box: Fast Track to Pomalyst Coverage in North Carolina

Aetna (CVS Health) requires prior authorization for Pomalyst (pomalidomide) with documented failure of lenalidomide plus a proteasome inhibitor. Submit PA via Availity portal with REMS enrollment proof, treatment timeline, and oncology notes. If denied, file internal appeal within 180 days, then request Smart NC external review. Start today: Call 1-855-240-0535 to verify your plan's PA requirements and download the correct form.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Essentials
  5. Documentation Packet
  6. Submission Mechanics
  7. Specialty Pharmacy Routing
  8. After Submission: Tracking Your Request
  9. Denial-Prevention Tips
  10. Appeals Process in North Carolina
  11. Printable One-Pager Checklist

Who Should Use This Checklist

This comprehensive checklist is designed for North Carolina patients and their healthcare teams seeking Aetna (CVS Health) coverage for Pomalyst (pomalidomide) for multiple myeloma or Kaposi sarcoma. You'll need this if:

  • Your oncologist has prescribed Pomalyst but Aetna requires prior authorization
  • You've received a denial and need to appeal or request an exception
  • You're switching from another therapy and want to prevent delays

Expected outcome: Following this checklist systematically can reduce approval time from weeks to days and significantly improve your chances of coverage approval on the first submission.

Member & Plan Basics

✓ Verify Active Coverage

  • Confirm current Aetna enrollment via member portal or 1-855-240-0535
  • Check that your plan includes prescription drug benefits (not all do)
  • Verify your member ID matches exactly on all submissions

✓ Identify Your Plan Type

North Carolina Aetna members typically have one of these plan types, each with different PA processes:

Plan Type PA Portal Special Notes
Commercial (Individual/Group) Availity Standard PA timeline: 30 days
Medicare Advantage CoverMyMeds or Availity Expedited options available
Medicaid (Aetna Better Health NC) State-specific forms Different formulary rules

✓ Check Deductible Status

  • Log into your Aetna member portal to confirm deductible met/remaining
  • Note: Specialty drugs like Pomalyst may have separate deductibles

Clinical Criteria Requirements

✓ FDA-Approved Indications

Aetna covers Pomalyst for these specific conditions:

Multiple Myeloma:

  • Relapsed/refractory multiple myeloma
  • Must be used in combination with dexamethasone
  • Patient has received ≥2 prior therapies including lenalidomide AND a proteasome inhibitor
  • Disease progression within 60 days of last therapy

Kaposi Sarcoma:

  • HIV-positive patients after HAART failure
  • HIV-negative patients (monotherapy)

✓ Step Therapy Documentation

Aetna requires documented failure or intolerance of:

  1. Lenalidomide (Revlimid) - Include:
    • Start and stop dates
    • Highest dose achieved
    • Reason for discontinuation (progression, toxicity, contraindication)
    • Supporting labs or imaging showing progression
  2. Proteasome Inhibitor (bortezomib, carfilzomib, or ixazomib) - Include:
    • Treatment regimen and duration
    • Best response achieved
    • Documentation of progression or intolerance
Note: If patient hasn't tried these agents, document specific contraindications with clinical rationale.

✓ REMS Program Compliance

Pomalyst requires PS-Pomalidomide REMS enrollment:

  • Prescriber certified in REMS program
  • Patient enrolled with signed Patient-Physician Agreement
  • REMS authorization number obtained
  • Pregnancy testing plan documented (if applicable)

Coding & Billing Essentials

✓ ICD-10 Diagnosis Codes

Use the most specific code for your patient:

Condition ICD-10 Code Notes
Multiple myeloma, not in remission C90.00 Most common for new PA
Multiple myeloma, in remission C90.01 Use for maintenance
Multiple myeloma, in relapse C90.02 Use for retreatment
Kaposi's sarcoma (HIV+) C46.9 Include HIV status

✓ NDC and Billing Codes

Pomalyst is an oral specialty drug without a specific J-code:

Common NDCs by strength:

  • 1 mg: 59572-0501-21
  • 2 mg: 59572-0502-21
  • 3 mg: 59572-0503-21
  • 4 mg: 59572-0504-21

HCPCS for professional billing: J8999 (unclassified oral chemotherapy)

Documentation Packet

✓ Provider Note Elements

Your oncologist's note should include:

Patient Information:

  • Full name, DOB, member ID
  • Primary diagnosis with staging
  • ECOG performance status
  • Relevant comorbidities

Treatment History:

  • Chronological list of all prior myeloma therapies
  • Dates, doses, duration for each regimen
  • Response to treatment (complete response, partial response, stable disease, progression)
  • Reason for discontinuation with supporting data

Current Clinical Status:

  • Recent labs (CBC, comprehensive metabolic panel, M-protein levels)
  • Imaging results if applicable
  • Bone marrow biopsy results
  • Disease progression documentation

✓ Letter of Medical Necessity Components

Opening paragraph:

  • Patient identification and diagnosis
  • Specific drug requested (Pomalyst 4mg capsules)
  • Clear statement of medical necessity

Clinical rationale:

  • Why Pomalyst is appropriate for this patient's condition
  • Reference to NCCN Guidelines for multiple myeloma
  • Explanation of combination with dexamethasone

Prior therapy documentation:

  • Detailed history of lenalidomide exposure and failure
  • Proteasome inhibitor trial with outcomes
  • Any other relevant prior therapies

Safety considerations:

  • Patient counseled on embryo-fetal toxicity
  • REMS enrollment completed
  • Monitoring plan outlined

✓ Required Attachments

  • Pathology report confirming multiple myeloma diagnosis
  • Recent lab results and imaging
  • Prior therapy records with dates and outcomes
  • REMS Patient-Physician Agreement (signed)
  • Office notes from last 2-3 visits

Submission Mechanics

✓ Correct Form Selection

Use the current Aetna PA form for your plan type:

✓ Portal vs. Fax Submission

Preferred method: Availity Provider Portal

  • Faster processing (24-72 hours typical)
  • Automatic confirmation numbers
  • Real-time status updates

Fax backup: 1-855-330-1716 (verify current number)

  • Include cover sheet with member ID
  • Request fax confirmation receipt
  • Follow up within 48 hours

✓ Required Fields That Commonly Cause Rejections

Double-check these before submitting:

  • Member ID matches insurance card exactly
  • Provider NPI number included
  • ICD-10 diagnosis code complete (not just C90)
  • Specific drug name and strength
  • Prescriber DEA number
  • REMS authorization number
  • Requested quantity and day supply

Specialty Pharmacy Routing

✓ Aetna Preferred Specialty Pharmacies

Pomalyst must be dispensed through a REMS-certified specialty pharmacy. Aetna's preferred options include:

  • CVS Specialty Pharmacy: 1-800-237-2767
  • Accredo (Express Scripts): Check if in-network for your plan
  • BioPlus Specialty Pharmacy: Verify network status

✓ Transfer Steps

  1. Confirm PA approval before transferring prescription
  2. Provide specialty pharmacy with PA authorization number
  3. Verify patient's shipping address and contact information
  4. Confirm REMS enrollment status with pharmacy

✓ Shipment Verification

  • Track shipping via pharmacy's portal
  • Ensure someone available to receive temperature-controlled shipment
  • Verify correct medication and quantity upon receipt

After Submission: Tracking Your Request

✓ Confirmation Numbers to Record

  • PA submission confirmation number
  • Date and time of submission
  • Contact name if submitted by phone

✓ Status Check Schedule

  • Day 2-3: Check portal or call for initial review status
  • Day 7: Follow up if no response received
  • Day 14: Escalate if still pending beyond standard timeline

✓ What to Record

Maintain a log with:

  • All communication dates and reference numbers
  • Names of representatives spoken to
  • Any additional information requested
  • Approval or denial notification details

Denial-Prevention Tips

Common Pitfall #1: Incomplete REMS Documentation

Fix: Ensure both prescriber and patient REMS enrollment is complete before PA submission. Include the authorization number prominently in your request.

Common Pitfall #2: Insufficient Prior Therapy Documentation

Fix: Create a detailed timeline showing specific dates of lenalidomide and proteasome inhibitor therapy, with clear documentation of progression or intolerance.

Common Pitfall #3: Wrong Prescriber Specialty

Fix: Ensure PA is submitted by or co-signed by a hematologist/oncologist. Primary care or other specialists often trigger automatic denials.

Common Pitfall #4: Missing Combination Therapy Note

Fix: Clearly state that Pomalyst will be used in combination with dexamethasone, as required by FDA labeling for multiple myeloma.

Common Pitfall #5: Inadequate Medical Necessity Justification

Fix: Reference specific NCCN guideline recommendations and explain why formulary alternatives are inappropriate for this patient's clinical situation.

Appeals Process in North Carolina

If your initial PA is denied, North Carolina offers robust appeal rights through the Smart NC program.

✓ Internal Appeal (First Level)

  • Timeline: Must file within 180 days of denial
  • Method: Use form provided in denial letter or call 1-855-240-0535
  • Documentation: Submit additional clinical evidence addressing specific denial reasons
  • Decision time: 30 days for standard, 72 hours for expedited

✓ Smart NC External Review

If Aetna upholds the denial after internal appeal, North Carolina residents can request independent external review:

  • Eligibility: Fully insured plans regulated by NC DOI
  • Timeline: 120 days from final internal denial
  • Contact: Smart NC at 1-855-408-1212
  • Expedited option: Available if delay could jeopardize health
  • Binding: IRO decision is final and binding on Aetna
Tip: Smart NC staff can help you complete the external review application and gather supporting documentation.

✓ When to Request Expedited Review

Ask for expedited processing if:

  • Patient has rapidly progressing multiple myeloma
  • Delay could seriously jeopardize health or ability to regain function
  • Patient is currently hospitalized or in active treatment

Printable One-Pager Checklist

Before You Start: □ Active Aetna coverage verified
□ Member ID and plan type confirmed
□ Prescriber is hematologist/oncologist

Clinical Requirements: □ Multiple myeloma or Kaposi sarcoma diagnosis confirmed
□ Prior lenalidomide therapy documented with failure/progression
□ Prior proteasome inhibitor therapy documented
□ REMS enrollment completed for prescriber and patient

Documentation Ready: □ Provider note with complete treatment history
□ Letter of medical necessity referencing NCCN guidelines
□ Pathology report and recent labs
□ REMS Patient-Physician Agreement signed

Submission: □ Correct PA form for plan type
□ All required fields completed accurately
□ REMS authorization number included
□ Submitted via Availity portal (preferred) or fax

Follow-up: □ Confirmation number recorded
□ Status checks scheduled
□ Appeal strategy ready if denied

Need help navigating this process? Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients and clinicians get prescription drugs approved by identifying denial reasons and drafting point-by-point rebuttals aligned to each plan's specific rules.

For complex cases involving specialty drugs like Pomalyst, having expert support can make the difference between approval and costly delays. Counterforce Health provides the clinical evidence, procedural expertise, and payer-specific workflows needed to maximize your chances of coverage.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific Aetna plan and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, contact Smart NC at 1-855-408-1212.

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