By Counterforce Health Team in Blenrep (belantamab mafodotin) —

Getting Blenrep (Belantamab Mafodotin) Covered by Aetna (CVS Health) in Washington: Complete Access Guide for Current and Future Approval

Answer Box: Current Blenrep Access Through Aetna in Washington

Blenrep (belantamab mafodotin) is not commercially available through standard Aetna coverage due to its 2022 FDA withdrawal, with re-approval anticipated October 2025. Current access requires clinical trial enrollment or GSK expanded access programs. Washington residents denied coverage can appeal through Aetna's internal process, then file for external review with an Independent Review Organization (IRO) through the Washington State Office of the Insurance Commissioner within 30 days. First step today: Contact GSK at 1-844-447-5662 to explore compassionate use eligibility while preparing for potential 2025 commercial access.

Table of Contents

Current Coverage Status

Blenrep (belantamab mafodotin) was voluntarily withdrawn from the U.S. market by GSK in November 2022 following FDA discussions about efficacy data. The drug is currently under FDA review with a PDUFA date of October 23, 2025 for potential re-approval.

What This Means for Aetna Coverage

  • No active HCPCS J-code for billing (previously J9037)
  • Not listed in Aetna's 2025 precertification requirements or formulary guides
  • Classified as experimental/investigational for standard coverage denials
  • No standard prior authorization pathway until potential FDA re-approval

Access Options While Off-Market

GSK Expanded Access Program

The primary route for obtaining Blenrep is through GSK's compassionate use program:

Eligibility Requirements:

  • Age 18 or older
  • Relapsed/refractory multiple myeloma
  • ≥4 prior therapies including lenalidomide, proteasome inhibitor, and anti-CD38 antibody
  • Treatment at REMS-certified center

How to Apply:

  1. Healthcare provider contacts GSK at 855-209-9188
  2. Complete expanded access application with clinical documentation
  3. Obtain REMS certification for ocular monitoring
  4. Submit to Aetna if insured (may require prior authorization)

Clinical Trial Options

Search for active Blenrep trials at ClinicalTrials.gov using search terms "belantamab mafodotin" and "multiple myeloma." Washington residents have access to trials at major cancer centers including Seattle Cancer Care Alliance and University of Washington Medicine.

Preparing for Future FDA Re-Approval

If FDA re-approves Blenrep in October 2025, having documentation ready will expedite the coverage process.

Documentation Checklist

Document Type Details Where to Obtain
Treatment History Complete record of prior therapies, dates, outcomes Oncology clinic records
Diagnosis Codes ICD-10 C90.02 (relapsed/refractory MM) Medical records
Lab Results SPEP, immunofixation, free light chains Recent labs (within 30 days)
REMS Enrollment Baseline eye exam, monitoring plan Ophthalmology records
Prescriber Letter Medical necessity, rationale, goals Oncologist

Historical Prior Authorization Criteria

Based on pre-withdrawal Aetna policies, expect similar requirements for re-approval:

Medical Necessity Criteria:

  • Relapsed or refractory multiple myeloma after ≥4 prior therapies
  • Prior treatment with anti-CD38 monoclonal antibody (daratumumab)
  • Prior treatment with proteasome inhibitor (bortezomib, carfilzomib, ixazomib)
  • Prior treatment with immunomodulatory agent (lenalidomide, pomalidomide)
  • REMS program enrollment for ocular monitoring

Aetna Prior Authorization Process (Post-Approval)

Once FDA re-approves Blenrep, the standard Aetna prior authorization process will apply.

Submission Methods

  • Phone: 1-855-582-2025 (TTY: 711)
  • Fax: 1-855-330-1716
  • Mail: Aetna PA, 1300 E. Campbell Rd., Richardson, TX 75081
  • Online: Aetna provider portal or CoverMyMeds

Timeline Expectations

  • Standard review: 30 days
  • Expedited review: 72 hours (with medical urgency documentation)
  • CVS Specialty processing: Additional 1 week for fulfillment
Tip: Submit through electronic portals like CoverMyMeds for faster processing compared to fax submissions.

Washington State Appeals Process

Washington residents have robust appeal rights under RCW 48.43.535, with external review available through Independent Review Organizations.

Internal Appeals with Aetna

Level 1 Appeal (within 180 days of denial):

  • Mail: Aetna Appeals Resolution Team, PO Box 14463, Lexington, KY 40512
  • Fax: 1-859-425-3379
  • Timeline: 30 days standard, 72 hours expedited

Level 2 Appeal (within 60 days of Level 1 denial):

  • Same submission methods
  • Independent medical review

External Review Process

After exhausting internal appeals, Washington residents can request external review:

How to File:

  1. Download form from insurance.wa.gov/external-review
  2. Submit within 30 days of final internal denial
  3. Mail to: External Review Coordinator, PO Box 40255, Olympia, WA 98504-0255
  4. Or fax: 360-586-3535

Timeline: 45 days standard, 72 hours expedited for urgent cases

Cost: Free to consumer; decision is binding on Aetna

Note: Contact the Washington Office of the Insurance Commissioner at 1-800-562-6900 for assistance with the external review process.

Cost and Financial Assistance

GSK Patient Support Programs

Patient Assistance Program (PAP):

  • Eligibility: Household income limits (e.g., $78,200 for single person)
  • Benefit: Free medication for qualifying patients
  • Contact: 1-844-447-5662

Copay Program:

  • Eligibility: Commercial insurance required
  • Benefit: Reduce out-of-pocket costs (up to $26,000 lifetime maximum)
  • Enrollment: Online at togetherwithgsk.com/blenrep

Independent Foundation Grants

Several foundations provide copay assistance for multiple myeloma treatments:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

Contact the GSK Nurse Navigator at 1-844-447-5662 for current foundation availability and eligibility requirements.

CVS Specialty Pharmacy Coordination

Once commercially available, Blenrep will be dispensed through CVS Specialty Pharmacy due to its specialty drug classification.

Key Coordination Points

Aspect CVS Specialty Role Retail Pharmacy Role
Dispensing Primary dispenser; handles benefit verification and delivery Cannot dispense; forwards scripts to specialty
Prior Authorization Submits PA requests to Aetna Flags PA requirement only
REMS Compliance Manages enrollment and monitoring No REMS capability
Contact 1-866-814-5506 Varies by location

Script Routing Process

  1. Prescriber e-prescribes to CVS Specialty Pharmacy
  2. CVS Specialty verifies benefits and PA status
  3. Patient contacted for delivery coordination
  4. Average fulfillment: 1 week post-PA approval

Common Denial Scenarios and Solutions

Denial Reason Solution Strategy Required Documentation
Experimental/Investigational External review with FDA guidance FDA approval letter, clinical studies
Not Medically Necessary Medical necessity appeal Treatment history, oncologist letter
Step Therapy Failure Document prior failures Therapy records, intolerance notes
Non-Formulary Formulary exception request Alternative assessment, clinical rationale

Clinician Corner: Medical Necessity Letter Components

When preparing appeals, oncologists should include:

Essential Elements:

  • Patient diagnosis with ICD-10 codes
  • Complete treatment history with dates and outcomes
  • Clinical rationale for Blenrep vs. alternatives
  • NCCN guideline references (when available post-approval)
  • REMS monitoring plan
  • Treatment goals and expected outcomes

Supporting Evidence:

  • Recent imaging or lab results
  • Performance status documentation
  • Prior therapy intolerance or contraindications

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned to each payer's specific requirements, incorporating the right clinical evidence and procedural details that reduce back-and-forth with insurers.

FAQ

Q: How long does Aetna prior authorization take for specialty drugs in Washington? A: Standard prior authorization decisions take up to 30 days, with expedited reviews completed within 72 hours for urgent medical situations.

Q: Can I appeal an Aetna denial for experimental treatments in Washington? A: Yes. Washington law allows external review of experimental/investigational denials through Independent Review Organizations, with decisions binding on Aetna.

Q: What if Blenrep becomes non-formulary when re-approved? A: You can request a formulary exception by demonstrating medical necessity and that formulary alternatives would be less effective or cause adverse effects.

Q: Does Washington have special protections for rare disease drugs? A: Washington's external review process applies to all medical necessity denials, including rare disease treatments, with independent specialist review.

Q: How do I get help with my Aetna appeal in Washington? A: Contact the Washington Office of the Insurance Commissioner at 1-800-562-6900 for free assistance with appeals and external review requests.

Q: Will my current multiple myeloma treatment be covered while waiting for Blenrep approval? A: Yes, Aetna covers FDA-approved multiple myeloma treatments per their formulary. Work with your oncologist to optimize current therapy while monitoring Blenrep's approval status.

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 plan for specific coverage decisions. Appeal rights and processes may vary by plan type and can change over time. Counterforce Health provides tools and resources to help navigate insurance coverage challenges, but outcomes cannot be guaranteed.

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