By Counterforce Health Team in Blenrep (belantamab mafodotin) —

Getting Blenrep (Belantamab Mafodotin) Covered by Aetna CVS Health in Florida: Complete Prior Authorization and Appeal Guide

Answer Box: How to Get Blenrep Covered by Aetna CVS Health in Florida

Aetna CVS Health requires prior authorization for Blenrep (belantamab mafodotin) with criteria including ≥4 prior therapy failures, documented disease progression, and REMS enrollment for ocular monitoring. Submit PA via Aetna provider portal with complete treatment history. If denied, file internal appeal within 180 days, then request Florida external review for binding decision. Start by gathering prior therapy documentation and contacting CVS Specialty at 1-866-814-5506.

Table of Contents

  1. Coverage Policy Overview
  2. Medical Necessity Requirements
  3. Step Therapy and Exception Pathways
  4. Prior Authorization Process
  5. Appeals Process in Florida
  6. Required Documentation
  7. Common Denial Reasons and Solutions
  8. Cost Assistance Options
  9. Frequently Asked Questions

Coverage Policy Overview

Aetna CVS Health covers Blenrep (belantamab mafodotin) as a specialty medication requiring prior authorization across all plan types in Florida. The drug is processed through CVS Specialty/Accredo and must meet specific clinical criteria.

Important Update: Blenrep was temporarily withdrawn from the U.S. market in November 2022 but received new FDA approval in 2025 for combination therapy with bortezomib and dexamethasone in relapsed/refractory multiple myeloma.

Plan Types and Coverage

  • Commercial Plans: Standard PA required
  • Medicare Advantage: Coverage decisions within 72 hours if expedited
  • Medicaid (Aetna Better Health FL): Processed via CVS Caremark with state oversight

Medical Necessity Requirements

FDA-Approved Indication

Blenrep is approved for adults with relapsed or refractory multiple myeloma in combination with bortezomib and dexamethasone after at least one prior line of therapy.

Clinical Eligibility Criteria

Based on Aetna's specialty drug processes and industry standards:

Requirement Documentation Needed
Confirmed multiple myeloma diagnosis Pathology report, bone marrow biopsy
Prior therapy failures Treatment timeline with dates, responses, toxicities
Disease progression Recent labs (SPEP, free light chains), imaging
Performance status ECOG ≤2 or equivalent assessment
REMS enrollment Baseline ophthalmologic exam, monitoring plan

REMS Compliance Requirements

The FDA-mandated REMS program requires:

  • Baseline comprehensive eye exam
  • Eye exams before each dose for first 8 cycles
  • Dose modifications for keratopathy
  • Patient education on vision monitoring

Step Therapy and Exception Pathways

Standard Step Therapy Requirements

Aetna typically requires documentation of:

  1. Proteasome inhibitor (bortezomib, carfilzomib, or ixazomib)
  2. Immunomodulatory agent (lenalidomide or pomalidomide)
  3. Anti-CD38 antibody (daratumumab or isatuximab)

Medical Exception Process

Submit exceptions via Aetna's formulary exception process when:

  • Standard therapies caused intolerable side effects
  • Patient has contraindications to preferred agents
  • Disease progression despite adequate trials

Expedited exceptions are available within 24 hours for commercial plans when delay could jeopardize health.

Prior Authorization Process

Step-by-Step Submission

  1. Verify Coverage (Day 0)
  2. Gather Documentation (Days 1-2)
    • Complete treatment history
    • Recent lab values and imaging
    • REMS enrollment confirmation
    • Prescriber letter of medical necessity
  3. Submit PA Request (Day 3)
    • Online: Aetna provider portal
    • Phone: Non-specialty: 1-800-294-5979, Specialty: 1-866-814-5506
    • Fax: Specialty PA: 1-866-249-6155
  4. Review Timeline
    • Standard decisions: 15 business days maximum
    • Expedited (urgent): 24-72 hours
    • Additional information requests: Respond within 48 hours
Tip: Electronic submissions through CoverMyMeds or the Aetna portal typically process faster than fax submissions.

Appeals Process in Florida

Internal Appeals

For Aetna CVS Health denials in Florida, you have 180 days from the denial notice to file an internal appeal.

Commercial Plans:

  • File via Aetna disputes portal
  • Decision within 30-45 business days
  • Expedited appeals: 72 hours for urgent cases

Medicare Plans:

  • Submit to: Aetna Medicare Part D Appeals, PO Box 14579, Lexington, KY 40512
  • Standard appeals: 7 days
  • Expedited appeals: 72 hours

Florida External Review

After exhausting internal appeals, Florida law provides for binding external review through the Florida Department of Financial Services.

Timeline: 4 months from final internal denial to request external review Cost: No charge to consumers Decision: Binding on Aetna if reviewer finds in your favor

Required Documentation

Medical Necessity Letter Checklist

Your oncologist's letter should include:

✓ Patient Information

  • Full name, DOB, Aetna member ID
  • Multiple myeloma diagnosis with ICD-10 code (C90.x)

✓ Clinical History

  • Date of initial diagnosis
  • Staging and risk stratification
  • Prior treatment regimens with specific dates
  • Response to each treatment and reason for discontinuation

✓ Current Status

  • Recent disease assessment (within 30 days)
  • Laboratory values (SPEP, immunofixation, free light chains)
  • Performance status assessment

✓ Treatment Rationale

✓ Safety Planning

  • Ophthalmology consultation arranged
  • REMS program enrollment
  • Monitoring schedule

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
"Not medically necessary" Provide detailed treatment history, NCCN guideline citations, peer-reviewed evidence
"Experimental/investigational" Reference FDA approval, established clinical data from DREAMM trials
"Step therapy not met" Document prior failures, intolerances, or contraindications to preferred agents
"Non-formulary" Request formulary exception with clinical justification
"Quantity limits exceeded" Provide dosing rationale based on FDA labeling and patient-specific factors

Peer-to-Peer Review

Request a peer-to-peer review with Aetna's medical director when denials are based on medical necessity. This allows your oncologist to directly discuss the case with Aetna's reviewing physician.

Cost Assistance Options

While Blenrep was off-market, cost assistance programs were limited. With re-approval, patients should check:

  • GSK Patient Assistance: Contact GSK directly for current programs
  • Foundation Support: Organizations like CancerCare may provide copay assistance
  • State Programs: Florida residents may qualify for additional support through state pharmaceutical assistance programs
Note: Verify current assistance programs with the manufacturer, as offerings may have changed with the drug's re-introduction.

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in Florida? Standard PA decisions are made within 15 business days. Expedited requests for urgent cases are decided within 24-72 hours.

What if Blenrep is not on my Aetna formulary? You can request a formulary exception through Aetna's medical exception process. Provide clinical justification for why formulary alternatives are inappropriate.

Can I request an expedited appeal in Florida? Yes, expedited appeals are available when delay could seriously jeopardize your health. These must be decided within 72 hours for most plan types.

Does step therapy apply if I received prior treatments outside Florida? No, prior treatments received anywhere should count toward step therapy requirements. Provide complete documentation of all prior therapies regardless of location.

What happens if my internal appeal is denied? You can request external review through the Florida Department of Financial Services within 4 months of the final internal denial. This review is binding on Aetna.

How do I find an ophthalmologist for REMS monitoring? Aetna's provider directory can help locate in-network eye specialists. The prescribing oncologist may also have referral recommendations for REMS-experienced ophthalmologists.

About Counterforce Health: Counterforce Health specializes in turning insurance denials into successful appeals by creating evidence-backed, payer-specific appeals that address the exact criteria insurers use to make coverage decisions. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and craft compelling medical necessity arguments.

If you're facing a Blenrep denial from Aetna CVS Health in Florida, Counterforce Health can help optimize your appeal documentation by identifying the specific denial basis and crafting targeted rebuttals aligned with Aetna's own coverage policies and Florida's appeal requirements.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies and appeal processes may change. Always consult with your healthcare provider and insurance plan for the most current information specific to your situation. For assistance with insurance complaints in Florida, contact the Florida Department of Financial Services at 1-877-693-5236.

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