Pomalyst (pomalidomide) — CareFirst (Caremark)

Multiple myeloma

Initial criteria

Authorization may be granted when any of the following criteria are met:
Member has previously received at least two prior regimens for multiple myeloma including an immunomodulatory agent and proteasome inhibitor and the requested medication will be used in one of the following regimens: in combination with elotuzumab and dexamethasone; in combination with ixazomib and dexamethasone if lenalidomide- or anti-CD-38 refractory; in combination with cyclophosphamide and dexamethasone; in combination with isatuximab-irfc and dexamethasone if bortezomib- or lenalidomide-refractory; in combination with dexamethasone; in combination with selinexor and dexamethasone; or as a single agent.
OR Member has previously received at least one prior regimen for multiple myeloma and the requested medication will be used in one of the following regimens: in combination with carfilzomib and dexamethasone; in combination with bortezomib and dexamethasone if lenalidomide- or anti-CD-38 refractory; in combination with carfilzomib, daratumumab, and dexamethasone; or in combination with daratumumab and dexamethasone if immunomodulatory agent and proteasome inhibitor were previously given and disease is bortezomib- or lenalidomide-refractory.

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

12 months