Medicare AdvantagePrior AuthMedium impact
Pomalyst (pomalidomide) (Revised)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Jan 1, 2022
We identified it
Jun 25, 2026
Summary
Humana revised its Pomalyst (pomalidomide) prior authorization policy for Medicare Advantage members effective January 1, 2022, with a revision date of May 27, 2026. This pharmacy policy maintains strict prior authorization requirements for multiple myeloma and Kaposi sarcoma indications, with no substantive coverage criteria changes from the previous version. Billing teams should verify current policy compliance for all Pomalyst requests, as the policy requires documentation of prior therapy failures and disease progression before approval.
Action Required
By June 30, 2026: Verify all Pomalyst (pomalidomide) prior authorization requests submitted to Humana Medicare Advantage plans comply with current policy criteria. Specifically: (1) For multiple myeloma cases, confirm documentation shows at least 2 prior therapies, disease progression on/within 60 days of last therapy, and prior failure on both a lenalidomide (Revlimid) or thalidomide (Thalomid) agent AND a proteasome inhibitor; (2) Confirm the requested combination therapy matches approved regimens (single agent, or with dexamethasone and one specified agent); (3) For Kaposi sarcoma cases, verify AIDS-related diagnosis after HAART failure OR HIV-negative status; (4) Confirm no prior disease progression documented on Pomalyst. Update prior authorization submission templates and provider ordering guidelines to include checklist items matching these criteria. Billing team should flag any requests missing this documentation and return them to providers before submission. Failure to meet criteria will result in claim denials.