Can pomalidomide be included in medical insurance in 2025, and what is the reimbursement policy?

Pomalidomide (Pomalidomide), as a third-generation immunomodulator, has unique efficacy in the treatment of relapsed or refractory multiple myeloma. It is often used clinically in combination with dexamethasone for patients who have failed treatment with lenalidomide and a proteasome inhibitor (such as bortezomib). Since these patients usually have a long disease course and limited treatment options, pomalidomide is regarded as one of the important late-line treatments.

In terms of medical insurance policy, China's National Medical Insurance Administration has included pomalidomide in the scope of medical insurance reimbursement, but there are strict conditions for use. According to the latest reimbursement list, the drug is suitable for adult patients with multiple myeloma who have received at least two previous treatments (including lenalidomide and proteasome inhibitors) and whose disease has progressed during or within 60 days of the last treatment. In other words, only patients who meet the above-mentioned relapse or refractory criteria can be eligible for reimbursement according to medical insurance regulations.

Drugs included in medical insurance, especially imported original drugs, usually need to go through price negotiations to ensure that drug prices are within a controllable range. Although pomalidomide was originally priced at a relatively high price, often costing tens of thousands of yuan per box, through the national medical insurance negotiation mechanism, the proportion of out-of-pocket payments after medical insurance in some areas is currently on a downward trend, and the specific proportions vary depending on provincial and municipal policies. It is worth noting that the medical insurance drug catalogs in some areas also require patients to be diagnosed in a tertiary hospital and pass an expert group evaluation before they can enter the "medical insurance payment path." That is to say, although the drug is included in the medical insurance, there is a "threshold" for the use path.

In addition, since pomalidomide is a specially controlled drug with a high risk of teratogenicity, female patients must strictly avoid contraception during use, which also affects its scope of use in certain groups of people. Patients are required to sign an informed consent form before taking medication and receive medication education and guidance from pharmacists. These are also included in the risk assessment process before taking medication under medical insurance.

Reference materials:https://en.wikipedia.org/wiki/Pomalidomide