By Counterforce Health Team in Blenrep (belantamab mafodotin) —

Get Blenrep (Belantamab Mafodotin) Covered by Blue Cross Blue Shield Michigan: Complete PA and Appeal Guide

Answer Box: Getting Blenrep Coverage in Michigan

Blenrep (belantamab mafodotin) is currently withdrawn from the U.S. market but under FDA review for potential resubmission (PDUFA date October 23, 2025). Blue Cross Blue Shield of Michigan requires prior authorization for this specialty oncology drug when available, and current access is limited to clinical trials or expanded access programs. If denied, you have 180 days to appeal internally, then 127 days to file for external review with Michigan DIFS. Start by verifying your specific BCBSM plan's formulary status and submitting a Medical Drug Prior Authorization Request Form through your provider.

First step today: Contact your oncologist to confirm trial enrollment options or expanded access eligibility, then call BCBSM at the number on your member ID card to verify current coverage policies.

Table of Contents

  1. Coverage at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Forms and Submission Portals
  4. Specialty Pharmacy Coordination
  5. Appeals Playbook for BCBSM in Michigan
  6. Common Denial Reasons & Solutions
  7. Support Contacts and Case Management
  8. When to Escalate to Michigan Regulators
  9. FAQ

Coverage at a Glance

Requirement What it means Where to find it Source
PA Required Prior authorization needed for medical benefit drugs BCBSM Medical Drug PA List BCBSM Provider Portal
Current Status Withdrawn from market; trial/expanded access only FDA Orange Book FDA
Formulary Tier Check 2025 Drug Lists for your specific plan BCBSM Drug Lists BCBSM
Appeals Deadline 180 days from denial (commercial plans) BCBSM Appeal Form BCBSM
External Review 127 days from final internal denial Michigan DIFS Michigan DIFS
Specialty Pharmacy Walgreens Specialty or limited distribution BCBSM Specialty Guide BCBSM

Step-by-Step: Fastest Path to Approval

1. Verify Current Drug Status and Plan Coverage

Who: Patient and provider
Action: Contact BCBSM member services (number on ID card) to confirm Blenrep's current formulary status and any trial coverage policies
Timeline: Same day
Document needed: Member ID, provider NPI

2. Explore Clinical Trial or Expanded Access Options

Who: Oncologist
Action: Check ClinicalTrials.gov for active Blenrep studies or contact GSK for expanded access programs
Timeline: 1-2 weeks for enrollment screening
Document needed: Medical records, prior treatment history

3. Submit Prior Authorization Request

Who: Provider
Action: Complete BCBSM Medical Drug Prior Authorization Request Form with multiple myeloma diagnosis (ICD-10), prior therapies, and medical necessity justification
Timeline: 5-15 business days for determination
Portal: BCBSM Provider Portal or fax to specialty pharmacy

4. Coordinate with Specialty Pharmacy

Who: Patient/Provider
Action: If approved, work with Walgreens Specialty Pharmacy (1-866-515-1355) for dispensing and REMS monitoring coordination
Timeline: 3-5 days for first shipment
Requirements: REMS enrollment, ophthalmology monitoring plan

5. Appeal if Denied

Who: Patient or authorized representative
Action: Submit internal appeal using BCBSM Appeal Form within 180 days
Timeline: Standard review 5-14 days, expedited 24-48 hours
Required: Denial letter, updated medical records, physician letter

Forms and Submission Portals

Prior Authorization Forms

Medical Drug Prior Authorization Request Form

  • Access: BCBSM Provider Portal > Authorization > Medical Drug PA
  • Required fields: Patient demographics, ICD-10 codes, medication details, clinical justification
  • Processing time: 5-15 business days (standard), expedited available for urgent cases

Member Appeal Form (Optional)

  • Download: BCBSM Appeal Form PDF
  • Submission: Mail to BCBSM, 600 E. Lafayette Blvd., M.C. 1620, Detroit, MI 48226-2998
  • Fax: 877-522-4767

Submission Portals and Methods

Method Contact Best for Notes
Provider Portal bcbsm.com/providers PA submissions Requires provider credentials
Walgreens Specialty Fax 1-866-515-1356 Prescription submission Include PA approval number
Member Portal Member ID card number Appeal tracking Log in with member credentials

Specialty Pharmacy Coordination

Walgreens Specialty Pharmacy (Primary)

  • Phone: 1-866-515-1355 (Mon-Fri 8 a.m.-8 p.m., Sat 8 a.m.-8 p.m.)
  • Fax: 1-866-515-1356
  • Services: Home delivery, copay assistance coordination, REMS monitoring support
  • Website: WalgreensSpecialtyRx.com
Tip: For Blenrep, coordinate ophthalmology monitoring requirements with your specialty pharmacy before first shipment. The REMS program requires regular eye exams.

Limited Distribution Options

If Blenrep becomes available through limited distribution when reintroduced:

  • Optum Frontier: 1-855-768-9727
  • Orsini Specialty Pharmacy: 1-800-410-8575
  • Onco360°: 1-877-662-6633

Appeals Playbook for BCBSM in Michigan

Internal Appeals (First Level)

Standard Internal Appeal

  • Deadline: 180 days from denial notice
  • Timeline: 5-14 business days for decision
  • Submission: Mail, fax (877-522-4767), or provider portal
  • Required documents: Denial letter, medical records, physician letter of medical necessity

Expedited Internal Appeal

  • Deadline: As soon as possible (no specific limit for urgent cases)
  • Timeline: 24-48 hours
  • Trigger: Physician documentation that delay would jeopardize health
  • Contact: Number on member ID card

External Review (Michigan DIFS)

Standard External Review

  • Deadline: 127 days from final internal denial
  • Timeline: Up to 60 days for decision
  • Cost: Free to consumers
  • Submission: DIFS External Review Portal or Form FIS 0018
  • Phone support: 877-999-6442

Expedited External Review

  • Deadline: 10 days from adverse determination
  • Timeline: 72 hours for decision
  • Requirements: Physician letter confirming delay would jeopardize life, health, or maximum function
  • Not available for: Post-service claims
Note: DIFS external review decisions are binding on BCBSM. If approved, your insurer must provide coverage as directed.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
"Not commercially available" Demonstrate clinical trial enrollment or expanded access approval Trial enrollment letter, GSK expanded access approval
"Lack of REMS monitoring" Establish ophthalmology monitoring plan Ophthalmologist letter, monitoring schedule
"Insufficient prior therapies" Document failed standard treatments Treatment history, progression notes, intolerance documentation
"Off-label use attempted" Clarify FDA-approved indication for relapsed/refractory multiple myeloma FDA labeling, NCCN guidelines, clinical evidence

Clinician Corner: Medical Necessity Letter Checklist

When drafting appeals for Blenrep coverage, include:

✓ Diagnosis: Relapsed/refractory multiple myeloma with specific ICD-10 codes
✓ Prior treatments: Document at least 4 prior therapies per FDA label requirements
✓ Treatment failures: Specific reasons for discontinuation (progression, intolerance)
✓ Clinical rationale: Why Blenrep is medically necessary over alternatives
✓ Monitoring plan: REMS compliance and ophthalmology coordination
✓ Guidelines: Reference NCCN Multiple Myeloma Guidelines supporting BCMA-targeted therapy

Support Contacts and Case Management

BCBSM Member Services

  • General inquiries: Number on member ID card
  • Provider relations: (800) 437-3803
  • Pharmacy clinical help: Mail Code 512J, P.O. Box 441877 (for formulary questions)

Specialty Drug Support

  • Walgreens Specialty: 1-866-515-1355
  • Optum Home Delivery: 1-855-811-2223 (BCBSM), 1-844-642-9087 (BCN)
  • TTY (hearing impaired): 711

Case Management Tips

When calling BCBSM:

  1. Have your member ID, provider information, and denial letter ready
  2. Ask for case management if dealing with complex specialty drug issues
  3. Request reference numbers for all calls and document conversation details
  4. Ask about expedited review options if treatment is time-sensitive

When to Escalate to Michigan Regulators

Contact Michigan DIFS if you experience:

  • Procedural violations: BCBSM not following required timelines or processes
  • Repeated denials without justification: Pattern of inappropriate denials
  • Access to care issues: Delays that jeopardize health outcomes

Michigan Department of Insurance and Financial Services (DIFS)

  • Consumer hotline: 877-999-6442
  • Online complaints: michigan.gov/difs
  • External review portal: Available 24/7 for filing appeals

Counterforce Health helps patients navigate complex appeals by analyzing denial letters and drafting targeted, evidence-backed responses that address specific payer criteria. Their platform can be particularly valuable for specialty drug appeals where clinical evidence must be precisely aligned with insurer requirements.

FAQ

How long does BCBSM prior authorization take for specialty drugs like Blenrep? Standard processing is 5-15 business days. Expedited reviews (24-48 hours) are available when a physician documents that delays would jeopardize patient health.

What if Blenrep is non-formulary on my BCBSM plan? You can request a formulary exception by submitting an appeal with medical necessity documentation. Include evidence of failed preferred therapies and clinical rationale for Blenrep specifically.

Can I request expedited appeal for Blenrep denial? Yes, if your oncologist provides written documentation that treatment delays would jeopardize your health or maximum function. Contact the number on your member ID card immediately.

Does step therapy apply if I've already failed therapies outside Michigan? Prior treatment history from other states typically counts toward step therapy requirements. Provide complete medical records documenting failed therapies and reasons for discontinuation.

What's the difference between BCBSM internal and external appeals? Internal appeals are reviewed by BCBSM staff within their policies. External appeals are conducted by independent medical experts through Michigan DIFS and are binding on your insurer.

How much does Blenrep cost without insurance? Blenrep is currently not commercially available in the U.S. market. When reintroduced, pricing will be established. GSK may offer patient assistance programs for eligible patients.

Can my doctor appeal on my behalf? Yes, physicians can file appeals as your authorized representative with your written consent. This is often more effective as they can provide detailed clinical justification.

What happens if Michigan DIFS approves my external appeal? The decision is binding on BCBSM. Your insurer must provide coverage as directed by the independent review organization, typically within 30 days of the decision.

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Coverage policies vary by specific plan and individual circumstances. Always consult with your healthcare provider about treatment decisions and verify current coverage policies directly with your insurer. For assistance with complex appeals, consider working with advocacy organizations like Counterforce Health that specialize in insurance coverage challenges.

Sources & Further Reading

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