By Counterforce Health Team in Blenrep (belantamab mafodotin) —

Do You Qualify for Blenrep (Belantamab Mafodotin) Coverage by Humana in Ohio? Decision Tree & Next Steps

Answer Box: Quick Eligibility & Action Plan

Blenrep (belantamab mafodotin) was reapproved by the FDA on October 23, 2025 for relapsed/refractory multiple myeloma after ≥2 prior therapies. For Humana coverage in Ohio: (1) Confirm your diagnosis meets FDA criteria, (2) Have your oncologist submit prior authorization with clinical documentation to Humana at 877-486-2621, and (3) If denied, file an internal appeal within 65 days. Ohio residents with Medicare Advantage follow federal appeals; those with state-regulated plans can use Ohio's external review process after internal appeals.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If You're "Likely Eligible"
  4. If You're "Possibly Eligible"
  5. If You're "Not Yet Eligible"
  6. If You're Denied: Appeal Path Chooser
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. Frequently Asked Questions

How to Use This Guide

This decision tree helps Ohio residents determine their likelihood of getting Blenrep (belantamab mafodotin) covered by Humana and provides clear next steps based on your situation.

Start here: Answer the questions in the eligibility triage section below. Based on your answers, you'll fall into one of four categories, each with specific action items and timelines.

Important: Blenrep returned to the U.S. market in October 2025 after being withdrawn in 2022. The new indication is more specific than before, so previous coverage decisions may not apply.

Eligibility Triage: Do You Qualify?

Work through these questions with your oncologist to determine your coverage likelihood:

Step 1: Diagnosis Confirmation

  • Do you have relapsed or refractory multiple myeloma? ✓ Yes / ✗ No
  • Have you received at least 2 prior lines of therapy? ✓ Yes / ✗ No
  • Did those prior therapies include a proteasome inhibitor AND an immunomodulatory agent? ✓ Yes / ✗ No

Step 2: Clinical Requirements

  • Is your oncologist planning to use Blenrep in combination with bortezomib and dexamethasone? ✓ Yes / ✗ No
  • Do you have adequate organ function for treatment? ✓ Yes / ✗ No / ✗ Unknown
  • Are you enrolled in or eligible for the REMS monitoring program? ✓ Yes / ✗ No / ✗ Unknown

Step 3: Insurance Status

  • Do you have active Humana coverage? ✓ Yes / ✗ No
  • Is your plan Medicare Advantage, commercial, or Medicaid managed care? [Select one]

Your Result:

  • All "Yes" answers: You're Likely Eligible → Go to Section 3
  • 1-2 "No" or "Unknown" answers: You're Possibly Eligible → Go to Section 4
  • 3+ "No" answers: You're Not Yet Eligible → Go to Section 5

If You're "Likely Eligible"

Congratulations! You meet the basic criteria for Blenrep coverage. Here's your action plan:

Document Checklist

Gather these items before your oncologist submits the prior authorization:

Clinical Documentation:

  • Multiple myeloma diagnosis with ICD-10 code (C90.00-C90.02)
  • Complete treatment history showing ≥2 prior lines
  • Documentation of proteasome inhibitor and immunomodulatory agent use
  • Recent labs showing adequate organ function
  • ECOG performance status assessment

Insurance Information:

  • Current Humana member ID card
  • Prescription benefit details
  • Specialty pharmacy enrollment (if required)

Submission Path

  1. Your oncologist submits prior authorization to Humana at 877-486-2621
  2. Timeline: Standard decisions within 72 hours; expedited within 24 hours if urgent
  3. Follow-up: Check status via Humana provider portal or member services
Tip: Request expedited review if treatment delays could harm your health. Include a physician letter explaining the urgency.

If You're "Possibly Eligible"

You may qualify with additional testing or documentation. Here's what to track:

Tests to Request

  • Organ function panel: Kidney, liver, heart, and lung function tests
  • Performance status evaluation: ECOG score from your oncologist
  • Prior therapy documentation: Detailed records of previous treatments and responses

Timeline to Re-Apply

  • Complete missing tests: 1-2 weeks
  • Resubmit PA: Once all documentation is ready
  • Decision timeframe: 24-72 hours after complete submission

What to Track

Keep a log of:

  • Test results and dates
  • Prior medications tried (names, doses, duration, response)
  • Any treatment-related complications or intolerances

If You're "Not Yet Eligible"

Don't lose hope. Here are your options:

Alternatives to Discuss

Talk with your oncologist about these BCMA-targeted therapies that may be covered:

  • CAR-T cell therapy: Ciltacabtagene autoleucel (cilta-cel) or idecabtagene vicleucel (ide-cel)
  • Bispecific antibodies: Teclistamab or elranatamab
  • Clinical trials: May provide access to Blenrep or similar agents

Prepare for Exception Requests

If no alternatives work, your doctor can request a formulary exception based on:

  • Medical necessity despite not meeting standard criteria
  • Contraindications to preferred alternatives
  • Prior treatment failures with covered options

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps identify the specific denial basis and drafts point-by-point rebuttals aligned to your plan's own rules, potentially saving weeks of back-and-forth with your insurer.

If You're Denied: Appeal Path Chooser

Your appeal path depends on your specific Humana plan type:

Medicare Advantage Plans (Most Common)

Appeals follow federal Medicare rules, not Ohio state process:

  1. Internal Appeal (Level 1)
    • Deadline: 65 days from denial date
    • Timeline: 30 days for standard; 72 hours for expedited
    • How to file: Call member services or submit via portal
  2. Independent Review (Level 2)
    • Timeline: 30 days for standard; 72 hours for expedited
    • Automatic: Proceeds if Level 1 is denied
  3. Administrative Law Judge
    • Required amount: $200 minimum (2025)
    • Timeline: 90 days

State-Regulated Plans (Individual/Small Group)

Can use Ohio's external review process:

  1. Internal Appeal with Humana
    • Deadline: 65 days from denial
    • Timeline: 30 days for decision
  2. Ohio External Review
Note: ERISA employer plans follow federal rules and cannot use Ohio's external review process.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Doctor must get approval before prescribing Humana formulary or member portal Humana PA Process
REMS Enrollment Monitoring program for eye toxicity Oncologist handles enrollment FDA REMS Requirements
Combination Therapy Must use with bortezomib + dexamethasone FDA prescribing information FDA Approval Letter
Prior Therapy ≥2 lines including PI and IMiD Medical records documentation FDA Label
Appeals Deadline 65 days from denial notice Denial letter instructions Humana Member Rights

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
"Not FDA-approved for your condition" Submit updated FDA label (Oct 2025) Current FDA prescribing information
"Insufficient prior therapy" Document all previous treatments Complete treatment history with dates, responses
"REMS not enrolled" Complete REMS registration REMS enrollment confirmation from oncologist
"Not medically necessary" Request peer-to-peer review Clinical notes, NCCN guidelines, physician letter
"Experimental/investigational" Cite FDA approval date FDA approval letter dated October 23, 2025

Frequently Asked Questions

How long does Humana prior authorization take in Ohio? Standard requests: 72 hours. Expedited requests: 24 hours. Your oncologist can request expedited review if delays could harm your health.

What if Blenrep is not on Humana's formulary? Your doctor can request a formulary exception with clinical justification. Counterforce Health helps craft targeted appeals that address your plan's specific requirements.

Can I get expedited appeals in Ohio? Yes. Both Medicare Advantage and state-regulated plans offer expedited appeals for urgent medical situations. Request this if treatment delays could worsen your condition.

Does step therapy apply if I've tried treatments outside Ohio? Prior treatments count regardless of where you received them. Provide complete documentation of all previous therapies to your Ohio oncologist.

What's the difference between Medicare Advantage and regular Humana appeals? Medicare Advantage follows federal Medicare appeals rules. Other Humana plans may use Ohio's state external review process after internal appeals are exhausted.

How much does Blenrep cost with Humana coverage? Costs vary by plan. Check your specific formulary tier and copay structure. Manufacturer copay assistance may be available.

Who can help me navigate the appeals process in Ohio? Contact the Ohio Department of Insurance Consumer Services at 800-686-1526 for state-regulated plans, or Medicare for Medicare Advantage appeals.

What happens if my appeal is denied? You can pursue external review (for state plans) or higher-level Medicare appeals. You may also file complaints with Ohio regulators or explore legal options.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage decisions are made by individual insurers based on medical necessity and plan terms.

Need Help? Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by identifying denial patterns and crafting evidence-backed rebuttals aligned to each plan's specific requirements.

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