Pomalyst (pomalidomide) — Highmark

Initial criteria

• For multiple myeloma: age ≥ 18 years AND diagnosis of multiple myeloma (ICD-10 C90.0) AND at least two prior therapies including lenalidomide and a proteasome inhibitor AND progression on or within 60 days of last therapy
• For AIDS-related Kaposi sarcoma: age ≥ 18 years AND diagnosis of AIDS-related Kaposi sarcoma (ICD-10 C46.9) AND failure of highly active antiretroviral therapy (HAART)
• For HIV-negative Kaposi sarcoma: age ≥ 18 years AND diagnosis of Kaposi sarcoma (ICD-10 C46.9) AND member is HIV-negative

Reauthorization criteria

• The prescriber attests that the member is tolerating therapy AND
• The member has experienced a therapeutic response defined as disease improvement OR delayed disease progression

Approval duration

12 months