Subject: Specialty Quantity Limit Pomalyst 2387-H P2022
Policy:
I. PROGRAM DESCRIPTION
The standard limit is designed to allow a quantity sufficient for
the most common uses of the medication. The recommended
dosing parameters for all FDA-approved indications fall within
the standard limits. Coverage of an additional quantity may be
reviewed on a case-by-case basis upon request.
II. COVERED QUANTITIES
|
Medication
|
Standard Limit
|
FDA-recommended dosing
|
|
Pomalyst
(pomalidomide)
capsules 1mg
|
21 per 28 days
|
Multiple myeloma: 4 mg per day
taken orally on days 1-21 of repeated
28-day cycles
Kaposi Sarcoma: 5 mg per day taken
orally on days 1-21 of repeated 28-
day cycles
Dose Adjustments: 1 mg to 4 mg
once daily
|
|
Pomalyst
(pomalidomide)
capsules 2mg
|
21 per 28 days
|
|
Pomalyst
(pomalidomide)
capsules 3mg
|
21 per 28 days
|
|
Pomalyst
(pomalidomide)
capsules 4mg
|
21 per 28 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Pomalyst [package insert]. Summit, NJ: Celgene Corporation; October 2021.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
April 15, 2023
