By Counterforce Health Team in Blenrep (belantamab mafodotin) —

How to Get Blenrep (Belantamab Mafodotin) Covered by Blue Cross Blue Shield of Illinois: Coding, Appeals, and Current Access Options

Answer Box: Blenrep Coverage with Blue Cross Blue Shield of Illinois

Current Status: Blenrep (belantamab mafodotin) is not commercially available in the U.S. as of 2025—GSK withdrew it in 2022 pending FDA resubmission (PDUFA date October 2025). Blue Cross Blue Shield of Illinois (BCBSIL) requires prior authorization for specialty drugs, but Blenrep access is currently limited to clinical trials or expanded access programs only.

If seeking coverage for trial participation or future resubmission:

  1. Use ICD-10 code C90.02 (multiple myeloma, in relapse) for documentation
  2. Submit prior authorization through BCBSIL specialty pharmacy pathway
  3. Appeal denials within 60-180 days, then request external review within 30 days in Illinois

Next step: Contact your oncologist about clinical trials or expanded access programs while monitoring FDA approval status.

Table of Contents

Understanding Blenrep's Current Status

Blenrep (belantamab mafodotin-blmf) is an anti-BCMA antibody-drug conjugate that was voluntarily withdrawn from the U.S. market by GSK in November 2022. The manufacturer resubmitted the drug to the FDA with updated efficacy data, and the agency has set a PDUFA (Prescription Drug User Fee Act) date of October 23, 2025, for their decision.

What this means for patients:

  • No commercial availability in the U.S. currently
  • Access only through clinical trials or expanded access programs
  • Insurance coverage discussions are theoretical until FDA re-approval
Note: Even when Blenrep returns to market, it will require Risk Evaluation and Mitigation Strategy (REMS) monitoring due to severe ocular toxicity risks, including corneal epitheliopathy and vision changes.

BCBS Illinois Coverage Framework

Blue Cross Blue Shield of Illinois operates as part of the Health Care Service Corporation (HCSC) family and holds approximately 63% of the commercial insurance market in Illinois. Understanding their specialty drug coverage structure is crucial for future Blenrep access.

Coverage Pathways

Administration Method Benefit Type Prior Auth Required Typical Cost Share
IV infusion (clinic/hospital) Medical benefit Yes 15-35% after deductible
Specialty pharmacy dispensing Pharmacy benefit Yes Varies by formulary tier
Home infusion Medical or pharmacy Yes Often lower than facility

Key Requirements:

  • Prior authorization for all specialty oncology drugs
  • Use of designated specialty pharmacies (typically Accredo)
  • Medical necessity documentation
  • Step therapy compliance when applicable

Essential Coding for Multiple Myeloma

Accurate ICD-10 coding is fundamental to insurance approval. For relapsed/refractory multiple myeloma patients who would be candidates for Blenrep, use these specific codes:

Primary ICD-10 Codes

C90.02 - Multiple myeloma, in relapse

  • Use for patients with documented disease progression after initial treatment
  • Most appropriate for Blenrep candidacy
  • Requires clear documentation of relapse status

C90.00 - Multiple myeloma, not having achieved remission

  • For active disease that hasn't responded to initial therapy
  • Alternative when "relapse" terminology isn't clearly documented

Documentation Requirements

Your medical records must explicitly support the ICD-10 code selection:

  • Disease status: Clearly state "relapsed" or "refractory" multiple myeloma
  • Prior treatments: List specific regimens tried and failed
  • Current evidence: Include recent lab values, imaging, or bone marrow results showing active disease
  • Treatment history: Document at least 4 prior lines of therapy (typical Blenrep indication)
Clinician Corner: Insurance reviewers look for specific language. Use phrases like "relapsed after achieving partial response to lenalidomide-based therapy" rather than vague terms like "disease progression."

Product Coding and Billing

Understanding Blenrep's billing codes is essential for clean claims submission when the drug returns to market.

Current Billing Codes

HCPCS J-Code:

  • Previous code J9037 was deactivated March 31, 2025
  • Current billing requires J9999 (unclassified antineoplastic drug)
  • Units: Bill as 1 mg per unit (changed from 0.5 mg units)

NDC Information:

  • NDC: 00173-0896-01 (100 mg single-dose vial)
  • Report as "UN1" for Medicaid billing
  • Include 11-digit NDC on all claims

Billing Considerations

When Blenrep becomes available again:

  • Use J9999 until new specific J-code is assigned
  • Include JW/JZ modifiers for Medicare (drug waste reporting)
  • Add "UD" modifier for 340B purchases
  • Standard dose: 2.5 mg/kg IV every 3 weeks

Prior Authorization Requirements

BCBS Illinois requires prior authorization for all specialty oncology drugs. Here's what you need to know about the process:

Required Documentation

  1. Completed PA form (available through BCBSIL provider portal)
  2. Clinical notes documenting:
    • Confirmed multiple myeloma diagnosis
    • Disease staging and current status
    • Prior treatment history with specific agents and outcomes
    • Current performance status
  3. Laboratory results supporting active disease
  4. Letter of medical necessity from treating oncologist

Medical Necessity Criteria

BCBSIL typically requires evidence that Blenrep is:

  • FDA-approved for the patient's specific indication
  • Prescribed by an appropriate specialist (hematologist/oncologist)
  • Medically necessary based on current treatment guidelines
  • Not contraindicated due to patient-specific factors
Tip: Start the PA process early. BCBSIL has up to 15 business days for standard reviews, but complex cases may take longer.

Appeals Process in Illinois

If your initial prior authorization is denied, Illinois provides robust appeal rights with specific timelines.

Internal Appeals

Timeline: Submit within 60-180 days of denial (check your specific denial letter) Process:

  1. Submit written appeal to BCBSIL Grievance and Appeals Department
  2. Include all supporting documentation
  3. Request peer-to-peer review if appropriate
  4. Decision within 15 business days for pre-service requests

Contact Information:

  • Address: PO Box 660717, Dallas, TX 75266
  • Expedited Fax: 1-800-338-2227
  • Member Services: 800-538-8833

External Review (Illinois-Specific)

Illinois has stricter timelines than many states for external review requests.

Critical Deadline: You have only 30 calendar days from the internal appeal denial to request external review (shorter than the typical 4-month window in other states).

Process:

  1. Contact Illinois Department of Insurance
  2. Submit external review application
  3. Independent physician reviewer assigned
  4. Decision within 45 days (72 hours for urgent cases)
  5. Decision is binding on the insurer

Illinois DOI Contact:

  • Phone: 877-850-4740
  • Email: [email protected]
  • Address: 320 W. Washington Street, Springfield, IL 62767

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, identifies specific denial reasons, and drafts point-by-point rebuttals using the right medical evidence and payer-specific requirements—exactly what's needed for complex specialty drug appeals like those involving advanced multiple myeloma treatments.

Alternative Treatment Options

While awaiting Blenrep's return to market, several BCMA-targeted and other effective therapies are available for relapsed/refractory multiple myeloma:

BCMA-Targeted Alternatives

CAR-T Cell Therapies:

  • Abecma (ide-cel) - First-line BCMA CAR-T
  • Carvykti (cilta-cel) - Often preferred for certain patients

Bispecific Antibodies:

  • Tecvayli (teclistamab) - BCMA x CD3 bispecific
  • Elrexfio (elranatamab) - Alternative BCMA bispecific

Standard Combination Therapies

Depending on prior treatments, options may include:

  • Daratumumab-based triplets
  • Carfilzomib combinations
  • Pomalidomide regimens
  • Selinexor-based therapy
From Our Advocates: We've seen patients successfully transition from denied novel therapy requests to approved alternative BCMA-targeted treatments by working closely with their oncologist to document why the specific mechanism of action was clinically preferred. The key was demonstrating medical necessity for the BCMA target rather than the specific drug initially requested.

Costs and Patient Assistance

When Blenrep returns to market, cost will be a significant factor. Here are resources to explore:

Manufacturer Support

  • GSK Patient Assistance Programs (check GSK.com for updates)
  • Copay assistance cards (typically for commercially insured patients)
  • Patient access services through specialty pharmacies

Foundation Grants

  • HealthWell Foundation
  • Patient Access Network Foundation
  • Leukemia & Lymphoma Society
  • Multiple Myeloma Research Foundation

State Resources

  • Illinois Medicaid (expanded under ACA)
  • Illinois Department of Insurance consumer assistance: 877-527-9431

FAQ

Q: How long does BCBS Illinois prior authorization take? A: Standard PA decisions are made within 15 business days. Expedited reviews for urgent cases can be completed within 24-72 hours.

Q: Can I get Blenrep through clinical trials with insurance coverage? A: Yes, many clinical trials cover the investigational drug cost. Contact your oncologist about current trials or check ClinicalTrials.gov.

Q: What happens if Blenrep is non-formulary when it returns? A: You can request a formulary exception by demonstrating medical necessity and providing documentation that formulary alternatives are inappropriate.

Q: Does step therapy apply to specialty cancer drugs? A: BCBS Illinois may require step therapy, but oncologists can request exceptions based on clinical contraindications or prior treatment failures.

Q: How do I expedite an appeal in Illinois? A: Request expedited review if delays would seriously jeopardize your health. Provide supporting documentation from your physician about the urgency.

Q: What if I need Blenrep while traveling outside Illinois? A: BCBS Illinois typically provides coverage for emergency care nationwide, but planned treatments may require prior authorization and network provider coordination.

Sources & Further Reading

For comprehensive support with insurance appeals and prior authorization strategies, Counterforce Health offers specialized assistance in navigating complex specialty drug coverage challenges.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always consult with your healthcare provider and insurance company for the most current information regarding your specific situation. For assistance with insurance coverage issues in Illinois, contact the Illinois Department of Insurance at 877-527-9431.

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