Medical Policy

Effective Date:06/01/2013 Title:Pomalyst (Pomalidomide)
Revision Date:10/01/2015 Document:BI410:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Pomalyst (Pomalidomide) requires prior authorization.

2)    Pomalyst is used to treat multiple myeloma.

3)    Pomalyst is a specialty drug and must be obtained through a contracted specialty pharmacy.

Medical Statement

Pomalyst (Pomalidomide) is considered medically necessary for members who meet all the following criteria:

 

1)    Diagnosis of multiple myeloma  (C90.00 or C90.02) AND

2)    Have tried at least one month of Kyprolis (carfilzomib) AND

3)    Demonstrated disease progression on or within 60 days of completion of Kyprolis therapy.

Limits
Intentially left empty
Reference

1)    Pomalyst prescribing information. Summit (NJ): Celgene Corporation; February 2013.

2)    Clinical Pharmacology.  Pomalyst.  Accessed online May 2013.

3)    NCCN Guidelines Version 2.2013 Multiple Myeloma. Accessed May 2013.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.