Pharmacy Prior Authorization Criteria

Pomalyst (pomalidomide)

Indications for Prior Authorization

Pomalyst (pomalidomide)

• For diagnosis of Multiple myeloma
  Indicated, in combination with dexamethasone, for patients with multiple myeloma who have received at least two prior therapies including lenalidomide and a proteasome inhibitor and have demonstrated disease progression on or within 60 days of completion of the last therapy.

• For diagnosis of Kaposi Sarcoma
  Indicated for the treatment of:

  1) Adult patients with AIDS-related Kaposi sarcoma (KS) after failure of highly active antiretroviral therapy (HAART). 2) Kaposi sarcoma (KS) in adult patients who are HIV-negative.

  Note: this indication is approved under accelerated approval based on overall response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s).

Criteria

Pomalyst

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Multiple Myeloma

• Diagnosis of multiple myeloma

Pomalyst

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Kaposi Sarcoma

• One of the following:
• Diagnosis of AIDS-related Kaposi sarcoma
OR
• Both of the following:
• Diagnosis of Kaposi sarcoma
AND
• Patient is HIV-negative

Pomalyst

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of All Indications

• Patient does not show evidence of progressive disease while on therapy

P & T Revisions

2024-04-22, 2023-06-09, 2023-06-08, 2023-05-03, 2022-05-04, 2021-05-26, 2020-06-30, 2020-04-30

References

1. Pomalyst Prescribing Information, Celgene Corporation, Summit, NJ. March 2023.
2. National Comprehensive Cancer (NCCN) Drugs & Biologics Compendium [internet database]. Updated periodically. Available at: http://www.nccn.org/professionals/drug_compendium/content/contents.asp. Accessed April 22, 2024.

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Revision History

• 2024-04-22: 2024 annual review. Background updates. No changes to clinical intent.
• 2023-06-09: Removed prescriber requirement.
• 2023-06-08: Program update to consolidate under one umbrella Breast Cancer criterion. Removed any criteria related disease classification or combination/prior therapy. Cleaned up references and end notes.
• 2023-05-03: Annual review - updated references.
• 2022-05-04: Annual review - updated references.
• 2021-05-26: Annual review - updated references. Added EHB formulary.
• 2020-06-30: Added new indication for Kaposi sarcoma. Updated background and references.
• 2020-04-30: Annual review - removed reference to drug name in reauth criteria; updated references.

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