Pomalyst (pomalidomide) — CareFirst (Caremark)

Initial criteria

• Authorization may be granted when either of the following are met: requested medication will be used in combination with antiretroviral therapy for the treatment of HIV-related Kaposi sarcoma OR member is HIV-negative.

Reauthorization criteria

• Authorization may be granted for continued treatment when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Approval duration

12 months