By Counterforce Health Team in Blenrep (belantamab mafodotin) —

Getting Blenrep (Belantamab Mafodotin) Covered by UnitedHealthcare in Illinois: PA Requirements, Appeals, and Cost Support

Answer Box: Getting Blenrep Covered by UnitedHealthcare in Illinois

Important Update: Blenrep (belantamab mafodotin) was voluntarily withdrawn from the U.S. market in 2022. GSK resubmitted for FDA approval with a PDUFA date of October 23, 2025. Currently, access is limited to clinical trials or expanded access programs only.

For patients seeking coverage when Blenrep returns to market: UnitedHealthcare requires prior authorization through OptumRx. Submit PA requests via the UHC Provider Portal with medical necessity documentation. If denied, Illinois residents have strong appeal rights including external review through the Illinois Department of Insurance within 30 days of final denial. Start by calling OptumRx at 1-800-711-4555 to verify current formulary status.

Table of Contents

  1. Current Blenrep Availability Status
  2. UnitedHealthcare Coverage Requirements
  3. Prior Authorization Process
  4. Cost and Assistance Options
  5. Appeals Process in Illinois
  6. Specialty Pharmacy Requirements
  7. Preparing for Market Return
  8. FAQ

Current Blenrep Availability Status

Blenrep (belantamab mafodotin) is currently not commercially available in the United States. GSK voluntarily withdrew the drug from the market in November 2022 following discussions with the FDA about confirmatory trial results. The company has since resubmitted a Biologics License Application (BLA) with updated efficacy and safety data.

Key Timeline Information:

  • FDA PDUFA Date: October 23, 2025
  • Current Access: Limited to clinical trials and expanded access programs
  • Future Coverage: When approved, will require prior authorization through most insurers
Note: This guide prepares patients and providers for when Blenrep returns to market. Current access requires enrollment in clinical trials or GSK's expanded access program.

UnitedHealthcare Coverage Requirements

When Blenrep becomes commercially available, UnitedHealthcare will likely classify it as a specialty medication requiring prior authorization through OptumRx.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for specialty oncology drugs OptumRx PA Guidelines
Formulary Tier Expected specialty tier (SP) OptumRx Formulary
Step Therapy Possible for subsequent lines UHC Specialty Drug PA
Specialty Pharmacy Required through OptumRx network OptumRx Specialty
REMS Program Eye exam monitoring required FDA labeling requirement

Medical Necessity Criteria

Based on typical UnitedHealthcare policies for multiple myeloma treatments, Blenrep will likely require:

  • Diagnosis: Relapsed/refractory multiple myeloma with appropriate ICD-10 codes
  • Prior Therapies: Documentation of previous treatments and outcomes
  • Line of Therapy: Typically approved for patients who have received ≥4 prior therapies
  • BCMA Target: Rationale for anti-BCMA therapy approach
  • REMS Compliance: Ophthalmology monitoring plan

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Provider)
    • Use UHC Provider Portal PreCheck MyScript Tool
    • Confirm formulary status and PA requirements
    • Timeline: Real-time verification
  2. Gather Documentation (Provider + Patient)
    • Medical records showing MM diagnosis and staging
    • Prior therapy documentation with dates and outcomes
    • Current disease status and progression evidence
    • Ophthalmology clearance for REMS program
    • Timeline: 1-2 business days
  3. Submit PA Request (Provider)
    • Portal: UHC Provider Portal → Specialty Pharmacy section
    • Phone: 1-800-711-4555
    • Include all medical necessity documentation
    • Timeline: Same day submission
  4. PA Decision (UnitedHealthcare)
    • Standard review: 72 hours
    • Expedited review: 24 hours (if delay risks health)
    • Decision notification via portal and phone
  5. If Approved (Provider + Patient)
    • Coordinate with OptumRx Specialty Pharmacy
    • Schedule REMS eye exams
    • Timeline: 3-5 business days for delivery
  6. If Denied (Provider + Patient)
    • Request peer-to-peer review immediately
    • Prepare appeal documentation
    • Timeline: Begin within 24-48 hours

Required Documentation Checklist

  • Complete medical history and physical exam notes
  • Pathology report confirming multiple myeloma
  • Documentation of ≥4 prior therapy regimens with:
    • Treatment names and dates
    • Response duration
    • Reason for discontinuation
  • Current disease status (labs, imaging, bone marrow biopsy)
  • Ophthalmology evaluation and clearance
  • Prescriber attestation of medical necessity
Clinician Corner: Medical necessity letters should emphasize the unique anti-BCMA mechanism, prior therapy failures, and lack of suitable alternatives. Include specific response rates from the DREAMM clinical trials and reference NCCN guidelines for relapsed/refractory multiple myeloma treatment sequencing.

Cost and Assistance Options

Manufacturer Support Programs

GSK Together with BLENREP Program

  • Copay Card: Up to $26,000 annually for commercially insured patients
  • Patient Assistance Program: Free drug for qualifying uninsured/underinsured patients
  • Contact: 1-844-447-5662 (Together with GSK Oncology)
  • Eligibility: No Medicare/Medicaid patients for copay card

Key Requirements:

  • Commercial insurance coverage for Blenrep
  • Income limits for patient assistance program
  • U.S. residency and valid prescription

Independent Foundation Grants

Multiple myeloma-specific foundations may provide copay assistance:

  • Disease-based grants: Target "multiple myeloma" diagnosis funds
  • Income limits: Typically 400-500% of federal poverty level
  • Application timing: Funds open/close frequently
Tip: Contact the Together with BLENREP nurse navigator at 1-844-447-5662 to identify currently open foundation grants and receive application assistance.

UnitedHealthcare 2025 Specialty Drug Changes

  • $2,000 Out-of-Pocket Cap: Applies to Medicare Part D specialty drugs
  • Medicare Prescription Payment Plan: Spread costs over 12 months (~$167/month)
  • OptumRx Preferred Status: Lower costs through mail-order specialty pharmacy

Appeals Process in Illinois

Illinois provides strong patient protections through the Health Carrier External Review Act. UnitedHealthcare denials can be appealed through multiple levels.

Internal Appeals Process

Level 1: Standard Internal Appeal

  • Timeline to File: 180 days from denial
  • Decision Timeline: 30 days (pre-service), 15 days (post-service)
  • Required Documents: Denial letter, medical records, physician letter

Expedited Internal Appeal

  • When to Use: Delay would seriously jeopardize health
  • Decision Timeline: 24 hours
  • Same documentation as standard appeal plus urgency justification

External Review (Illinois DOI)

Eligibility: After final internal appeal denial

  • Timeline to File: 30 days from final internal denial (shorter than many states)
  • Cost: No fee to patient
  • Decision Timeline: 5 business days after IRO receives all materials
  • Binding: Yes, insurer must comply with favorable decisions

How to File External Review:

  1. Contact Illinois Department of Insurance: 1-877-527-9431
  2. Complete External Review Request form
  3. Include all supporting documentation
  4. IRO assigns independent physician reviewer
  5. Decision rendered within 45 days maximum
Illinois-Specific Advantage: The state's 30-day external review filing deadline is shorter than the typical 4-month window, but the 5-day IRO decision timeline is faster than most states.

When to Escalate

Contact Illinois Department of Insurance if:

  • UnitedHealthcare misses appeal deadlines
  • Denial lacks medical basis
  • PA process appears discriminatory
  • Contact: 1-877-527-9431 (Consumer hotline)

Specialty Pharmacy Requirements

UnitedHealthcare requires specialty medications like Blenrep to be dispensed through OptumRx's specialty pharmacy network.

OptumRx Specialty Coordination

Preferred Pharmacy: Optum Specialty Pharmacy (mail-order)

  • Benefits: Lower copays, 90-day supplies, clinical support
  • REMS Coordination: Integrated eye exam scheduling and monitoring
  • Delivery: Direct to patient or clinic

Retail Limitations:

  • Higher copays or full price
  • Limited REMS program access
  • Potential coverage denials

Practical Coordination Tips

  1. Enroll Early: Begin OptumRx specialty enrollment during PA process
  2. REMS Setup: Coordinate ophthalmology appointments before first dose
  3. Delivery Planning: Arrange secure delivery location and refrigeration
  4. Clinical Support: Utilize OptumRx nurse case managers

Preparing for Market Return

For Patients Currently in Trials

If you're receiving Blenrep through a clinical trial and the drug receives FDA approval:

  1. Transition Planning: Work with trial site to plan commercial transition
  2. Insurance Verification: Confirm UnitedHealthcare coverage before trial ends
  3. PA Preparation: Begin gathering commercial PA documentation
  4. REMS Continuity: Ensure eye exam monitoring continues seamlessly

For Patients Awaiting Access

Monitor FDA Decision: Track PDUFA date (October 23, 2025) for approval announcement

Prepare Documentation:

  • Organize complete treatment history
  • Maintain current disease status documentation
  • Establish ophthalmology relationship for REMS

Insurance Readiness:

  • Verify current UnitedHealthcare formulary status
  • Understand your plan's specialty drug benefits
  • Research manufacturer assistance programs

Counterforce Health specializes in helping patients navigate complex prior authorization and appeal processes for specialty medications like Blenrep. Their platform analyzes denial letters and creates targeted, evidence-backed appeals that align with specific payer policies and clinical guidelines.

FAQ

Q: How long does UnitedHealthcare prior authorization take for specialty drugs like Blenrep? A: Standard PA decisions are made within 72 hours. Expedited reviews (when delay risks health) are completed within 24 hours.

Q: What if Blenrep is non-formulary on my UnitedHealthcare plan? A: You can request a formulary exception with medical necessity documentation. The process follows similar timelines to PA requests.

Q: Can I request an expedited appeal in Illinois? A: Yes, both internal appeals and external reviews can be expedited if delay would seriously jeopardize your health or ability to regain maximum function.

Q: Does step therapy apply if I've failed multiple myeloma treatments outside Illinois? A: Treatment history from any location typically counts toward step therapy requirements. Provide complete documentation of all prior therapies regardless of where received.

Q: What's the difference between OptumRx mail-order and retail pharmacy costs? A: OptumRx specialty mail-order typically offers lower copays, 90-day supplies, and integrated REMS support. Retail pharmacies often have higher costs and limited specialty drug access.

Q: How do I get help with the appeals process in Illinois? A: Contact the Illinois Department of Insurance at 1-877-527-9431, or the Illinois Attorney General's Health Care Helpline at 1-877-305-5145 for assistance with appeals and external reviews.

Q: Will Medicare Part D cover Blenrep when it's approved? A: When approved, Blenrep will likely be covered under Medicare Part D with prior authorization. The 2025 $2,000 out-of-pocket cap will apply to reduce patient costs significantly.

Q: Can I use manufacturer copay cards with UnitedHealthcare Medicare plans? A: No, federal law prohibits manufacturer copay assistance for Medicare beneficiaries. However, the patient assistance program may help qualifying patients, and independent foundations provide grants for Medicare patients.

For patients facing complex specialty drug coverage challenges, Counterforce Health offers tools and expertise to turn insurance denials into successful appeals through targeted, evidence-based advocacy.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for the most current coverage policies and medical recommendations. Coverage policies and drug availability may change. Verify all information with official sources before making healthcare decisions.

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