WHA
 

Pomalyst (pomalidomide)

Indications for Prior Authorization

Pomalyst (pomalidomide)
  • For diagnosis of Multiple Myeloma
    Indicated for the treatment of adult patients, in combination with dexamethasone, for patients with multiple myeloma (MM) 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 adult patients with AIDS-related Kaposi sarcoma (KS) after failure of highly active antiretroviral therapy (HAART) or in patients with KS who are HIV-negative. 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

Brand Pomalyst, generic pomalidomide

Prior Authorization (Initial Authorization)

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

  • Diagnosis of multiple myeloma
Brand Pomalyst, generic pomalidomide

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
Brand Pomalyst, generic pomalidomide

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

  • Guideline ID
    GL-533223

  • Formulary
    premium

  • Effective date
    Apr 1, 2026

  • P&T approval date
    Feb 19, 2013

P & T Revisions

2026-03-02, 2025-05-01, 2024-04-22, 2023-06-09, 2023-06-08, 2023-05-03, 2022-05-04, 2021-05-26, 2020-06-30, 2020-04-30

  1. Pomalyst Prescribing Information. Celgene Corporation. Princeton, NJ. February 2025.
  2. Pomalidomide Prescribing Information. Aurobindo Pharma USA, Inc. East Windsor, NJ. June 2025.
  • 2026-03-02: Added generic pomalidomide capsules to guideline with no criteria changes. Operational update to add generic formulation to product name and background updates.
  • 2025-05-01: 2025 Annual Review. Background updates only.
  • 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.