By Counterforce Health Team in Blenrep (belantamab mafodotin) —

How to Get Blenrep (belantamab mafodotin) Covered by Aetna in Illinois: Complete Timeline & Appeals Guide

Answer Box: Getting Blenrep Covered by Aetna in Illinois

Blenrep (belantamab mafodotin) received FDA approval on October 23, 2025 for relapsed/refractory multiple myeloma. For Aetna coverage in Illinois:

  1. Check eligibility: Must have relapsed/refractory multiple myeloma after ≥2 prior therapies including a proteasome inhibitor and immunomodulatory agent
  2. Submit prior authorization via Aetna portal with complete clinical documentation (30-45 days standard, 72 hours expedited)
  3. If denied, appeal immediately: Illinois allows 180 days for internal appeals, then automatic external review with binding decisions

Start today: Verify your diagnosis meets FDA label criteria and gather prior therapy documentation. Submit PA requests via Aetna provider portal.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Yes, for medical necessity Aetna Precertification List Aetna Policy
FDA Indication Relapsed/refractory MM after ≥2 prior lines FDA Approval Letter FDA
REMS Program Required enrollment for ocular monitoring GSK REMS Information GSK
Combination Required With bortezomib + dexamethasone FDA Label FDA
Appeal Deadline 180 days (internal), 4 months (external) Illinois External Review Illinois DOI

What Affects Approval Timing

Several factors influence how quickly Aetna processes your Blenrep prior authorization in Illinois:

Benefit Type & Complexity

  • Commercial plans: 30-45 days standard review
  • Medicare Part D: 14 days for standard, expedited available
  • Medicaid managed care: 30-45 days typical

Documentation Completeness The most critical factor is submitting complete clinical evidence upfront. Aetna processes over 95% of complete urgent requests within 24 hours, but incomplete submissions can add weeks to the process.

Medical Urgency Mark requests "expedited" when delay could seriously jeopardize health. Illinois law requires expedited decisions within 72 hours for urgent cases.

Tip: Counterforce Health helps patients and clinicians navigate complex prior authorization processes by automatically identifying denial reasons and crafting targeted, evidence-backed appeals that align with each payer's specific requirements.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before submitting your Blenrep prior authorization, gather:

Patient Information:

  • Aetna member ID and policy details
  • Complete diagnosis with ICD-10 codes
  • Current weight and BSA for dosing calculations
  • Recent lab values and imaging results

Treatment History:

  • Detailed list of prior multiple myeloma therapies
  • Start/stop dates for each treatment
  • Reasons for discontinuation (progression, toxicity, intolerance)
  • Documentation of at least 2 prior lines including PI + IMiD

Clinical Documentation:

  • Recent oncology notes (within 30 days)
  • Pathology reports confirming multiple myeloma
  • Performance status assessment
  • Treatment goals and expected duration

Verify REMS Enrollment

Since Blenrep requires REMS participation due to ocular toxicity risks, ensure both prescriber and patient are enrolled before submission. This prevents automatic denials for REMS non-compliance.

Submission to Initial Review (1-5 Days)

How to Submit

Primary Method: Aetna Provider Portal

  • Fastest processing and real-time status tracking
  • Upload all documents in single submission
  • Automatic confirmation receipt

Alternative Methods:

  • Fax: 1-888-267-3277 (Aetna Specialty)
  • Phone: 1-888-632-3862 (Commercial plans)
  • EMR integration where available

What Reviewers Check First

Aetna's initial review focuses on:

  1. FDA indication alignment - Does diagnosis match approved use?
  2. Prior therapy requirements - Documented failure of ≥2 lines?
  3. Combination therapy - Prescribed with bortezomib + dexamethasone?
  4. REMS compliance - Provider and patient enrolled?
  5. Medical necessity - Clinical rationale provided?
Note: Illinois law requires expedited review within 72 hours when delay could jeopardize patient health.

Additional Information Requests (1-7 Days)

If Aetna requests additional information, respond within 24-48 hours to avoid delays. Common requests include:

  • More detailed prior therapy documentation
  • Recent lab values or imaging
  • Clarification of dosing rationale
  • Updated clinical notes
  • REMS enrollment confirmation

How to Respond Quickly:

  • Use the same submission method as original request
  • Reference the original PA case number
  • Include a cover letter summarizing new information
  • Send via secure portal for fastest processing

Decision Window & Outcomes

Typical Timelines

Review Type Standard Timeline Expedited Timeline
Commercial 30-45 days 72 hours
Medicare 14 days 72 hours
Medicaid 30-45 days 72 hours

Reading Your Approval Letter

Full Approval: Coverage approved for requested duration and dosing Partial Approval: Coverage with modifications (dose, frequency, duration) Conditional Approval: Coverage pending specific requirements (labs, monitoring)

Initial Approval Limitations

For outpatient hospital administration, Aetna limits initial approvals to 90 days for new therapy starts as of October 2025. Extensions require re-attestation of ongoing necessity.

If Denied: Appeals Process

Illinois Appeal Rights

Illinois provides robust appeal protections with automatic progression:

Internal Appeal (Level 1):

  • File within 180 days of denial
  • Decision required within 15 business days (expedited: 24 hours)
  • Use Aetna appeal forms

External Review (Automatic):

  • Automatically forwarded after internal denial unless you opt out
  • Must be filed within 4 months of final internal denial
  • Independent oncologist reviewer required
  • Decision within 72 hours (expedited) or 5 days (standard)
  • Binding decision - Aetna must comply

Getting Help with Appeals

Illinois Department of Insurance: 877-527-9431 Attorney General Health Care Helpline: 1-877-305-5145 Counterforce Health: Specializes in turning denials into targeted appeals

Renewal Cycles

Blenrep approvals typically require renewal every 3-6 months. To expedite renewals:

  • Submit 2-3 weeks before current approval expires
  • Include updated clinical notes showing response/tolerance
  • Document continued medical necessity
  • Provide current lab values and performance status

What Speeds Renewals:

  • Demonstrated clinical response
  • Good tolerance profile
  • Stable disease or better
  • Continued REMS compliance

Timeline Visual

Day 0: Submit complete PA request
↓
Days 1-5: Initial review and processing
↓
Days 6-12: Additional info requests (if needed)
↓
Days 13-45: Final decision (30-45 days standard)
↓
If Denied: Appeal within 180 days
↓
External Review: Decision within 5 days

Expedited Track: 72 hours maximum for urgent cases

Time-Saving Tips

  1. Use Aetna's Provider Portal - Fastest submission and tracking
  2. Submit Complete Packages - Include all documentation upfront
  3. Request Expedited Review - When medically appropriate
  4. Maintain REMS Compliance - Prevent automatic denials
  5. Follow Up Proactively - Check status every 3-5 business days
  6. Prepare Appeal Documentation - While waiting for initial decision
From our advocates: We've seen cases where complete, well-documented initial submissions with clear medical necessity rationale get approved in under a week, while incomplete submissions can take months. The key is front-loading all required clinical evidence and clearly connecting the patient's specific situation to FDA-approved indications.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Demonstrate FDA indication alignment Prior therapy failures, clinical notes
"Experimental/Investigational" Cite FDA approval (Oct 2025) FDA approval letter
"REMS non-compliance" Complete enrollment REMS certificates for provider/patient
"Insufficient prior therapy" Document ≥2 prior lines Detailed treatment history with dates
"Wrong combination" Confirm bortezomib + dexamethasone Updated prescription

Clinician Corner

Medical Necessity Letter Checklist

Your clinical documentation should address:

Problem Statement:

  • Confirmed multiple myeloma diagnosis with staging
  • Disease status (relapsed/refractory)
  • Performance status and prognosis

Prior Treatment History:

  • Minimum 2 prior lines of therapy
  • Include proteasome inhibitor and immunomodulatory agent
  • Specific agents, dates, duration, and outcomes
  • Reasons for discontinuation (progression vs. toxicity)

Clinical Rationale:

  • Why Blenrep is appropriate for this patient
  • Expected benefits based on DREAMM-7 trial data
  • Plan for ocular monitoring per REMS requirements

Guideline Support:

  • Reference FDA approval for specific indication
  • Cite relevant NCCN or ASCO guidelines
  • Include dosing rationale and administration plan

FAQ

How long does Aetna prior authorization take for Blenrep in Illinois? Standard review: 30-45 days. Expedited review: 72 hours maximum when medically urgent.

What if Blenrep is non-formulary on my plan? Request a formulary exception with clinical documentation showing medical necessity and prior therapy failures.

Can I request an expedited appeal in Illinois? Yes, if delay could jeopardize your health. Illinois requires expedited external review decisions within 72 hours.

Does step therapy apply to Blenrep? Potentially. Document failures of standard multiple myeloma therapies to support step therapy override.

What happens if my appeal is denied? In Illinois, you automatically qualify for external review by an independent oncologist. This decision is binding on Aetna.

How much does Blenrep cost without insurance? Pricing information is not yet available as the drug recently returned to market. Contact GSK for patient assistance programs.

Do I need to see a specialist for Blenrep? Yes, typically prescribed by hematologist/oncologists familiar with REMS requirements and multiple myeloma management.

What if I move out of Illinois during treatment? Appeal rights and processes may differ by state. Contact your new state insurance department for guidance.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for the most current requirements and procedures. For additional help with complex appeals, consider consulting with specialists like Counterforce Health who focus on turning insurance denials into successful approvals.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.