By Counterforce Health Team in Blenrep (belantamab mafodotin) —

Getting Blenrep (Belantamab Mafodotin) Covered by Aetna CVS Health in Georgia: Appeals Guide and External Review Process

Answer Box: Blenrep Coverage Path for Georgia Residents

Blenrep (belantamab mafodotin) is currently off-market in the US (withdrawn 2022, resubmission under FDA review). For Georgia residents with Aetna CVS Health, access is limited to clinical trials or expanded access programs. If denied coverage for trial participation or compassionate use:

  1. File internal appeal with Aetna within 180 days of denial
  2. Request external review through Georgia Department of Insurance within 60 days if denied
  3. Document medical necessity with oncologist support for alternative BCMA-targeted therapy

Contact Georgia DOI Consumer Services: 1-800-656-2298 for external review assistance.

Table of Contents

Understanding Blenrep's Current Status

Blenrep (belantamab mafodotin) was voluntarily withdrawn from the US market in November 2022 after the DREAMM-3 trial didn't meet its primary endpoint. GSK has resubmitted the drug to the FDA with additional data, and the PDUFA date is October 23, 2025. Currently, access is only through:

  • Clinical trials
  • Expanded access programs
  • International sources (not covered by US insurance)

For Georgia patients: If your oncologist is seeking coverage for Blenrep through a clinical trial or expanded access program, Aetna CVS Health may still deny coverage citing "experimental" or "investigational" status.

Note: Even off-market drugs can sometimes be covered if obtained through FDA-approved expanded access programs with proper documentation.

Georgia's Insurance Appeal Rights

Georgia law provides strong consumer protections for insurance denials, including specialty drug coverage. The state's external review process is binding on insurers and free for patients.

Key Georgia Protections:

Internal Appeals: You have 180 days from the date of denial to file an internal appeal with Aetna CVS Health.

External Review: After exhausting internal appeals, you have 60 days to request an independent external review through the Georgia Department of Insurance.

Step Therapy Override: Georgia law requires insurers to grant medical exceptions when:

  • The required drug is contraindicated
  • The patient previously failed the required therapy
  • The patient is stable on current medication
  • The required drug is expected to be ineffective

Coverage at a Glance

Requirement What It Means Timeline Source
Internal Appeal First level review by Aetna 180 days to file Georgia DOI Consumer Guide
External Review Independent review by GA DOI 60 days after internal denial Georgia DOI Process
Step Therapy Exception Override requirement for cheaper drug first 2 business days for decision GA Code § 33-24-59.25
Expedited Review Fast-track for urgent medical needs 72 hours Georgia DOI Process

Aetna CVS Health Prior Authorization Process

For multiple myeloma treatments, Aetna requires prior authorization for most specialty drugs. While Blenrep isn't commercially available, the PA process applies to alternative BCMA-targeted therapies.

Required Documentation:

  • Confirmed diagnosis with ICD-10 codes
  • Treatment history showing prior therapy failures
  • Clinical rationale for the specific therapy requested
  • Prescriber specialty (typically hematologist/oncologist required)
Clinician Corner: When documenting medical necessity, reference specific guideline recommendations from NCCN, ASH, or ESMO. Include progression dates, prior response durations, and contraindications to preferred formulary options.

CVS Caremark manages most Aetna specialty drug authorizations. Submit requests through the Aetna provider portal with complete clinical documentation.

Step Therapy Protections in Georgia

Georgia's step therapy law provides clear grounds for medical exceptions. For multiple myeloma patients, this is crucial when insurers require trying cheaper therapies first.

Exception Criteria (GA Code § 33-24-59.25):

Medical Exception Must Be Granted If:

  • Required drug is contraindicated due to patient's medical condition
  • Patient previously tried and failed the required medication
  • Required drug is expected to be ineffective based on patient characteristics
  • Patient is stable on current therapy and switching would be harmful

Documentation Language That Works:

"Requesting step therapy override per GA Code § 33-24-59.25 due to:

  • Patient previously demonstrated inadequate response to [required drug] as evidenced by progression on [date]
  • Current regimen has achieved stable disease for [duration]
  • Switching to required step therapy medication is expected to cause clinical deterioration based on prior treatment history"

Timeline: Aetna must respond within 2 business days for non-urgent requests, 24 hours for urgent situations.

External Review Process

When Aetna CVS Health denies coverage after internal appeals, Georgia residents can request binding external review through the state Department of Insurance.

Step-by-Step External Review Process:

  1. Complete Internal Appeals First (required except for urgent situations)
  2. File Within 60 Days of receiving final internal denial letter
  3. Submit Request to Georgia DOI Consumer Services: 1-800-656-2298
  4. Include Documentation:
    • All denial letters from Aetna
    • Medical records supporting necessity
    • Prescriber letter explaining clinical rationale
    • Evidence of prior therapy failures

External Review Timelines:

  • Standard Review: 30 days for decision
  • Expedited Review: 72 hours for urgent medical situations
  • Cost: Free for patients

Key Advantage: External review decisions are legally binding on Aetna CVS Health. If the independent reviewer approves coverage, Aetna must pay for the treatment.

Important: Self-funded employer plans (ERISA) may not be eligible for Georgia's external review process. Check with HR to determine if your Aetna plan is fully insured or self-funded.

Appeals Playbook for Aetna CVS Health

Level 1: Internal Appeal

Who Files: Patient or authorized representative (doctor, family member) Deadline: 180 days from denial date Method: Aetna member portal, phone, or written request Timeline: 30 days for standard, 72 hours for expedited Required: Denial letter, medical records, prescriber support

Level 2: External Review (Georgia DOI)

Who Files: Patient or representative Deadline: 60 days from final internal denial Method: Call 1-800-656-2298 or online form Timeline: 30 days standard, 72 hours expedited Cost: Free

Sample Phone Script for Aetna:

"I'm calling to file an internal appeal for the denial of [treatment]. My member ID is [number]. The denial was dated [date]. I have new clinical information showing medical necessity. Can you please start an expedited appeal due to my urgent medical condition?"

Alternative Coverage Strategies

Since Blenrep isn't commercially available, focus on coverage for alternative BCMA-targeted therapies:

FDA-Approved BCMA Options:

  • CAR-T therapies: Idecabtagene vicleucel (ide-cel), Ciltacabtagene autoleucel (cilta-cel)
  • Bispecific antibodies: Teclistamab, Elranatamab
  • Standard combinations: Daratumumab-based triplets

Financial Assistance:

  • Manufacturer programs: Most MM drug manufacturers offer patient assistance
  • Foundation grants: Leukemia & Lymphoma Society, Patient Access Network Foundation
  • State programs: Georgia may have limited specialty drug assistance programs

Companies like Counterforce Health specialize in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-based rebuttals that address specific denial reasons.

When to Escalate

Contact Georgia Department of Insurance If:

  • Aetna misses appeal deadlines
  • Denial letters lack proper rationale
  • Step therapy exceptions are wrongfully denied
  • External review requests are ignored

Georgia DOI Consumer Services: 1-800-656-2298 Online: File complaint at oci.georgia.gov

Additional Consumer Assistance:

  • Georgians for a Healthy Future: Nonprofit providing insurance appeal guidance
  • Georgia Legal Services: Free legal help for qualified individuals

FAQ

Q: Can I get Blenrep covered if it's not FDA-approved for commercial use? A: Coverage is extremely limited to clinical trials or expanded access programs. Focus appeals on alternative BCMA-targeted therapies that are commercially available.

Q: How long do Aetna CVS Health appeals take in Georgia? A: Internal appeals: 30 days standard, 72 hours expedited. External review through Georgia DOI: 30 days standard, 72 hours expedited.

Q: What if my Aetna plan is through my employer? A: Self-funded employer plans may not be eligible for Georgia's external review. Check with HR to determine your plan type. Fully insured plans qualify for state external review.

Q: Can I request an expedited appeal? A: Yes, if delays could seriously jeopardize your health. Provide clinical documentation of urgency from your oncologist.

Q: What happens if I miss the appeal deadline? A: Georgia allows 180 days for internal appeals and 60 days for external review. Missing deadlines may forfeit your appeal rights, but contact Georgia DOI Consumer Services for guidance.

Q: Does step therapy apply to multiple myeloma treatments? A: Yes, but Georgia law requires medical exceptions when clinically appropriate. Document prior failures and contraindications clearly.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Consult with your healthcare provider and insurance representative for guidance specific to your situation. Counterforce Health helps patients navigate insurance denials but cannot guarantee coverage outcomes.

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