By Counterforce Health Team in Blenrep (belantamab mafodotin) —

How to Get Blenrep (belantamab mafodotin) Covered by Aetna (CVS Health) in Pennsylvania: Appeals Guide with Forms and Timelines

Answer Box: Getting Blenrep Covered in Pennsylvania

Blenrep (belantamab mafodotin) received FDA approval on October 23, 2025, for adults with relapsed or refractory multiple myeloma. Aetna (CVS Health) requires prior authorization through CVS Caremark for this specialty drug. If denied, Pennsylvania's external review program overturns approximately 50% of specialty drug denials.

First steps today: 1) Have your oncologist submit prior authorization with complete medical records to CVS Caremark at 1-866-785-5714, 2) Document ≥2 prior therapy failures including proteasome inhibitor and immunomodulatory agent, 3) Ensure REMS program enrollment for ocular monitoring. If denied, file internal appeal within 180 days, then external review through Pennsylvania Insurance Department within 4 months.

Table of Contents

Understanding Blenrep Coverage Requirements

Blenrep returned to the U.S. market in October 2025 after FDA re-approval for relapsed or refractory multiple myeloma in combination with bortezomib and dexamethasone. The approval came after the original 2022 withdrawal due to failed confirmatory trials.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Must get approval before dispensing CVS Caremark: 1-866-785-5714 Aetna Precertification List
REMS Program Mandatory risk mitigation for ocular toxicity Prescriber must enroll in BLENREP REMS FDA Approval Letter
Step Therapy ≥2 prior lines including PI and IMiD Document therapy failures/intolerance CVS Caremark PA Process
ICD-10 Code C90.02 (relapsed/refractory multiple myeloma) Medical records must include diagnosis FDA Prescribing Information
Appeals Deadline 180 days from denial Track from denial letter date Aetna Member Handbook

Medical Necessity Criteria

Aetna typically requires documentation that you have:

  • Relapsed or refractory multiple myeloma diagnosis (ICD-10: C90.02)
  • Received at least two prior lines of therapy including a proteasome inhibitor and immunomodulatory agent
  • ECOG performance status 0-2 with adequate organ function
  • No existing corneal disease (except mild punctate keratopathy)
  • Treatment at a facility with REMS program enrollment

Reading Your Denial Letter

When Aetna denies Blenrep coverage, the denial letter will include specific reason codes. Common denial reasons include:

"Experimental/Investigational": This may appear if Aetna's formulary hasn't been updated since the October 2025 FDA approval. Include the FDA approval letter in your appeal.

"Step Therapy Not Met": You must document prior therapy failures. Gather records showing progression or intolerance to previous treatments.

"Not Medically Necessary": Often means missing clinical documentation. Your oncologist needs to provide detailed medical necessity letter.

"Non-Formulary": The drug may not be on Aetna's preferred list. Request formulary exception with supporting evidence.

Fixing Common Issues Before Appeal

Before filing a formal appeal, check if you can resolve these common issues:

Missing Documentation

  • Prior therapy records: Collect dates, doses, and outcomes of previous treatments
  • Lab values: Recent CBC, comprehensive metabolic panel, and organ function tests
  • Imaging: Latest scans showing disease status
  • Pathology reports: Confirming multiple myeloma diagnosis

Coding Issues

Ensure your oncologist uses correct codes:

  • ICD-10: C90.02 (relapsed or refractory multiple myeloma)
  • HCPCS: J9037 (when available for Blenrep)

REMS Program Status

Verify your prescriber is enrolled in the BLENREP REMS program. This is mandatory due to ocular toxicity risks and may cause automatic denials if not completed.

First-Level Appeal Strategy

Submit your internal appeal to Aetna within 180 days of the denial. Include these components:

Required Documents

  1. Denial letter and all related correspondence
  2. Medical necessity letter from your oncologist (see template below)
  3. Complete medical records from all treating physicians
  4. Prior therapy documentation with specific dates and outcomes
  5. FDA approval letter and prescribing information
  6. NCCN Guidelines pages (if applicable to your specific case)

Medical Necessity Letter Checklist

Your oncologist should address:

  • Diagnosis confirmation with staging and risk factors
  • Prior treatment history including specific agents, doses, duration, and reason for discontinuation
  • Clinical rationale for Blenrep based on FDA-approved indication
  • Monitoring plan for ocular toxicity and other adverse events
  • Treatment goals and expected outcomes
From our advocates: We've seen cases where including the specific DREAMM-7 trial data showing superior progression-free survival (51% risk reduction) alongside the patient's treatment history significantly strengthened the medical necessity argument. Always pair clinical trial evidence with the individual patient's circumstances.

Peer-to-Peer Review Process

If your written appeal is denied, request a peer-to-peer review. This allows your oncologist to speak directly with Aetna's medical director.

Scheduling the Call

Call CVS Caremark at 1-866-785-5714 and request a peer-to-peer review. Provide:

  • Member ID and case number
  • Prescribing physician's name and NPI
  • Preferred call times (usually within 72 hours)

Preparation Checklist

Before the call, your oncologist should have:

  • Complete patient chart readily available
  • FDA approval letter and key clinical trial data
  • Specific prior therapy failures documented
  • Alternative treatment options considered and ruled out

Pennsylvania External Review Program

If Aetna upholds the denial after internal appeals, Pennsylvania's Independent External Review program offers a final option with a 50% success rate for specialty drug appeals.

Eligibility Requirements

  • Completed Aetna's internal appeal process
  • Received Final Adverse Benefit Determination letter
  • Coverage denial based on medical necessity or experimental/investigational status
  • Request filed within 4 months of final denial

How to File

Submit your external review request through:

Required Documents

  • Final denial letter from Aetna
  • Insurance card copy
  • Medical records supporting medical necessity
  • Physician statement explaining why Blenrep is necessary

Timeline

  • Standard review: 45 days after IRO assignment
  • Expedited review: 72 hours (if delay could seriously harm your health)
  • Additional information: You have 15 days after IRO assignment to submit extra documentation

The Independent Review Organization's decision is binding on Aetna and must be implemented immediately if overturned.

Appeal Templates and Scripts

Patient Phone Script for Aetna

"Hello, I'm calling about a prior authorization denial for Blenrep, belantamab mafodotin, for my multiple myeloma treatment. My member ID is [ID number]. I received a denial letter dated [date] with reference number [number]. I'd like to file an internal appeal and request information about the peer-to-peer review process. Can you please transfer me to the appropriate department and provide the appeals submission address?"

Medical Necessity Letter Template

[Date]
[Aetna Medical Director]
[Address from denial letter]

RE: Appeal for Prior Authorization Denial - Blenrep (belantamab mafodotin)
Member: [Name], DOB: [Date], Member ID: [Number]

Dear Medical Director,

I am writing to appeal the denial of coverage for Blenrep (belantamab mafodotin) for my patient with relapsed/refractory multiple myeloma.

CLINICAL BACKGROUND:
[Patient] is a [age]-year-old with multiple myeloma initially diagnosed on [date]. Disease characteristics include [staging, cytogenetics, risk factors].

PRIOR THERAPY HISTORY:
1. [First line therapy] - [dates] - Discontinued due to [progression/toxicity]
2. [Second line therapy] - [dates] - Discontinued due to [progression/toxicity]
[Continue for all prior lines]

MEDICAL NECESSITY RATIONALE:
Blenrep received FDA approval on October 23, 2025, for adults with relapsed or refractory multiple myeloma who have received at least two prior therapies, including a proteasome inhibitor and an immunomodulatory agent. My patient meets these criteria.

The DREAMM-7 trial demonstrated superior progression-free survival with Blenrep plus bortezomib and dexamethasone compared to daratumumab-based therapy (median PFS significantly extended with 51% risk reduction).

MONITORING PLAN:
Patient will be monitored per REMS requirements including ophthalmologic evaluations before each dose and as clinically indicated for keratopathy and other ocular toxicities.

I respectfully request reconsideration of this denial based on FDA approval and demonstrated clinical benefit in this patient population.

Sincerely,
[Physician signature]
[Name, credentials]
[NPI number]

Tracking Your Case

Maintain detailed records throughout the appeals process:

Documentation Log

  • Submission dates for all appeals and documents
  • Reference numbers from Aetna for each interaction
  • Phone call logs with representative names and summaries
  • Deadline tracking for each appeal level
  • Document copies of everything submitted

Key Contacts

  • CVS Caremark Prior Authorization: 1-866-785-5714
  • Aetna Member Services: 1-800-872-3862
  • Pennsylvania Insurance Department: (877) 881-6388
  • External Review: [email protected]

When Appeals Fail: Alternative Options

If all appeals are unsuccessful, consider these alternatives:

Manufacturer Support Programs

GSK offers patient assistance programs for eligible individuals. Contact GSK at their patient support number (verify current contact information through GSK's official website).

Clinical Trials

Continue monitoring for ongoing DREAMM studies or other clinical trials through your oncologist or ClinicalTrials.gov.

Alternative Therapies

Discuss other BCMA-targeted options with your oncologist, including:

  • CAR-T therapies (ide-cel, cilta-cel)
  • Bispecific antibodies (teclistamab, elranatamab)
  • Other approved combinations per NCCN guidelines

State Complaint Process

File a complaint with the Pennsylvania Insurance Department if you believe Aetna violated state regulations during the review process.

FAQ

Q: How long does Aetna prior authorization take for Blenrep in Pennsylvania? A: Standard prior authorization decisions typically take 15 business days. Expedited reviews for urgent cases are completed within 72 hours if your physician certifies that delay could harm your health.

Q: What if Blenrep is not on Aetna's formulary? A: Request a formulary exception by providing medical necessity documentation and evidence that preferred alternatives are inappropriate or have failed.

Q: Can I get expedited review if I'm currently progressing? A: Yes, if your oncologist certifies that delay in treatment could seriously jeopardize your health, request expedited review for both internal appeals and Pennsylvania external review.

Q: Does step therapy apply if I received prior treatments outside Pennsylvania? A: No, prior therapy documentation from any location counts toward meeting step therapy requirements. Ensure all records are submitted with your appeal.

Q: What happens if the external review overturns Aetna's denial? A: Aetna must immediately provide coverage, including retroactive coverage if you paid out-of-pocket during the appeal process.

Q: How much does the Pennsylvania external review cost? A: The external review process is free for consumers. The state covers all costs associated with the independent review.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, plan policies, and clinical notes to identify the denial basis and draft point-by-point rebuttals aligned to each plan's specific requirements, pulling the right citations and clinical evidence to strengthen appeals.

For complex cases like Blenrep appeals, having expert support in navigating payer-specific workflows and procedural requirements can significantly improve approval chances. Counterforce Health provides the documentation, templates, and strategic guidance needed to build compelling cases that meet both medical necessity standards and administrative requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual circumstances and plan details. Always consult with your healthcare provider and insurance plan directly for specific guidance. For additional help with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department's consumer services line or visit their website for current resources and assistance programs.

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