By Counterforce Health Team in Blenrep (belantamab mafodotin) —

How to Get Blenrep (Belantamab Mafodotin) Covered by Cigna in North Carolina: Complete Appeals Guide

Answer Box: Getting Blenrep Covered by Cigna in North Carolina

Good news: Blenrep (belantamab mafodotin) received FDA approval in July 2025 for relapsed/refractory multiple myeloma. For Cigna coverage in North Carolina: (1) Your oncologist submits prior authorization showing you've tried at least four prior regimens, (2) If denied, file internal appeal within 180 days, (3) Use North Carolina's Smart NC external review if internal appeals fail—you have 120 days to file. Start by having your doctor call Cigna at 1-800-882-4462 for PA submission.

Table of Contents

  1. Coverage at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Clinician Corner: Medical Necessity Requirements
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Playbook for Cigna in North Carolina
  6. When Coverage Lapses: Bridge Options
  7. Annual Changes to Watch
  8. Personal Progress Tracker
  9. FAQ

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all specialty oncology drugs Cigna Provider Portal Cigna PA Policy
Formulary Tier Specialty tier (highest copay) Cigna Drug Lists National Preferred Formulary
Step Therapy Must have tried 4+ prior MM regimens Exception process available Cigna Oncology Policy
Site of Care REMS-enrolled infusion center only FDA requirement FDA Approval Letter
Appeals Deadline 180 days for internal appeals 120 days for NC external review Smart NC Guidelines

Step-by-Step: Fastest Path to Approval

1. Verify Your Eligibility

Who does it: You and your care team
What's needed: Confirm you have relapsed/refractory multiple myeloma with at least 2 prior therapies including a proteasome inhibitor and immunomodulatory agent
Timeline: Same day
Source: FDA-approved indication

2. Document Prior Treatment History

Who does it: Your oncologist's office
What's needed: Records showing you've tried at least 4 prior multiple myeloma regimens
How to submit: Include in PA request
Timeline: 1-2 business days to gather

3. Submit Prior Authorization

Who does it: Your oncologist
How to submit: CoverMyMeds portal or call 1-800-882-4462
Timeline: Cigna decides within 72 hours (24 hours if urgent)
Source: Cigna PA Timeline Policy

4. If Denied: Request Peer-to-Peer Review

Who does it: Your oncologist
What's needed: Clinical rationale for medical necessity
Timeline: Usually scheduled within 1-2 business days

5. File Internal Appeal if Still Denied

Who does it: You or your doctor
Where: Cigna appeals department
Timeline: 180 days from denial date
Expected decision: 30 days for standard, 72 hours for expedited

6. Request North Carolina External Review

Who does it: You
Where: Smart NC Department of Insurance
Timeline: 120 days after final internal denial
Decision: 45 days (3 days if expedited)

7. Contact Smart NC for Free Help

Who: You
Phone: 1-855-408-1212
What they provide: Free advocacy assistance with your external review

Clinician Corner: Medical Necessity Requirements

Medical Necessity Letter Checklist

Your oncologist should include these elements in the prior authorization request:

✓ Patient Problem:

  • Confirmed relapsed/refractory multiple myeloma diagnosis
  • ICD-10 code: C90.00 (Multiple myeloma not having achieved remission)
  • Disease progression despite prior therapies

✓ Prior Treatment History:

  • Document at least 4 prior regimens attempted
  • Include specific drugs, dates, duration of treatment
  • Outcomes: progression, intolerance, or inadequate response
  • Why alternatives are inappropriate or contraindicated

✓ Clinical Rationale:

  • Why Blenrep in combination with bortezomib and dexamethasone is appropriate
  • Patient's performance status and ability to tolerate treatment
  • Treatment goals and expected outcomes

✓ Guideline Citations:

  • FDA-approved indication for relapsed/refractory MM
  • NCCN Guidelines for Multiple Myeloma (if applicable)
  • Clinical trial data supporting the BVd regimen

✓ Dosing and Monitoring:

  • Proposed dosing: 2.5mg/kg IV every 3 weeks for 8 cycles, then maintenance
  • REMS program enrollment confirmation
  • Ophthalmologic monitoring plan for ocular toxicity
Note: The REMS program is mandatory due to serious ocular toxicity risks. Ensure your infusion center is REMS-enrolled before submitting the PA request.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documents Needed
"Insufficient prior therapies" Document 4+ failed regimens Complete treatment timeline with dates, drugs, outcomes
"Not medically necessary" Request peer-to-peer review Clinical notes, imaging showing progression, performance status
"Non-formulary drug" File formulary exception Exception request form with medical necessity letter
"Site of care restriction" Confirm REMS enrollment REMS-enrolled facility documentation
"Experimental/investigational" Cite FDA approval FDA approval letter dated July 2025

Appeals Playbook for Cigna in North Carolina

Internal Appeals Process

First Level Internal Appeal:

  • Timeline: 180 days from denial date
  • Decision timeframe: 30 days (72 hours if expedited)
  • How to file: Written request to Cigna appeals department
  • Required: Original denial letter, medical records, physician letter

Second Level Internal Appeal:

  • Timeline: 60 days from first-level denial
  • Decision timeframe: 30 days (72 hours if expedited)
  • Review: Independent medical reviewer

North Carolina External Review

Eligibility:

  • Must have exhausted Cigna's internal appeals
  • State-regulated plan (not self-funded ERISA plans)
  • Denial based on medical necessity or experimental treatment determination

How to File:

  1. Download the external review request form
  2. Include all denial letters and supporting medical records
  3. Submit within 120 days of final internal denial

Contact Smart NC:

  • Phone: 1-855-408-1212
  • Service: Free advocacy assistance
  • What they help with: Form completion, record gathering, communication with insurers

Decision Timeline:

  • Standard review: 45 days
  • Expedited review: 3 days (if delay would jeopardize health)
Important: External review decisions are binding on Cigna. If approved, they must provide coverage within 3 business days.

When Coverage Lapses: Bridge Options

Immediate Steps if Coverage Lapses

1. Contact Your Oncologist Immediately

  • Discuss temporary treatment modifications
  • Request samples if available
  • Consider alternative covered therapies as bridge

2. Manufacturer Support Programs

  • GSK Patient Assistance: Contact GSK directly for compassionate use options
  • Bridge programs may be available during appeals

3. Clinical Trial Access

  • Search ClinicalTrials.gov for ongoing Blenrep studies
  • Contact major cancer centers in North Carolina

4. Expedited Appeal Process

  • File expedited internal appeal if treatment delay would jeopardize health
  • Request expedited external review through Smart NC

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform can help identify the specific denial basis and draft point-by-point rebuttals aligned to your plan's requirements, potentially preventing coverage lapses through more effective initial submissions.

Annual Changes to Watch

Formulary Updates

  • When: January 1st each year
  • What to check: Blenrep's formulary tier and coverage criteria
  • Where to find: Cigna drug lists

Policy Changes

  • REMS modifications: Monitor FDA updates on ocular toxicity monitoring requirements
  • Step therapy updates: Changes to required prior therapies
  • Site of care restrictions: Updates to approved infusion centers

North Carolina Regulatory Changes

  • New pharmacy laws: The SCRIPT Act (effective October 2025) may affect specialty drug access
  • External review updates: Monitor Smart NC for process changes

Personal Progress Tracker

Key Dates to Track

  • PA submission date: ___________
  • Cigna decision deadline: ___________ (72 hours from submission)
  • Internal appeal deadline: ___________ (180 days from denial)
  • External review deadline: ___________ (120 days from final internal denial)

Important Contacts

  • Oncologist's office: ___________
  • Cigna member services: 1-800-244-6224
  • Smart NC helpline: 1-855-408-1212
  • Specialty pharmacy: ___________

Documents Checklist

  • ☐ Insurance card and policy information
  • ☐ Complete treatment history with dates
  • ☐ All denial letters and EOBs
  • ☐ Physician medical necessity letters
  • ☐ Lab results and imaging reports
  • ☐ REMS enrollment confirmation

FAQ

Q: How long does Cigna prior authorization take for Blenrep? A: Cigna must decide within 72 hours for non-urgent requests and 24 hours for urgent requests. If they don't respond within these timeframes, the request is automatically approved.

Q: What if Blenrep is not on Cigna's formulary? A: Your doctor can request a formulary exception by demonstrating medical necessity. Use Cigna's exception request form and include clinical justification.

Q: Can I get an expedited appeal in North Carolina? A: Yes, both Cigna and Smart NC offer expedited reviews when delays would seriously jeopardize your health. Expedited external reviews are decided within 3 days.

Q: Does step therapy apply if I received prior treatments in another state? A: Yes, your complete treatment history counts regardless of where you received care. Ensure your oncologist documents all prior therapies with dates and outcomes.

Q: What if my employer plan is self-funded? A: Self-funded ERISA plans may not be eligible for North Carolina's external review unless the employer opted into the system. Check with HR or contact Smart NC at 1-855-408-1212 to verify eligibility.

Q: How much will Blenrep cost with Cigna coverage? A: As a specialty tier drug, expect high copays or coinsurance. Contact Cigna member services at 1-800-244-6224 for your specific out-of-pocket costs and check with GSK about patient assistance programs.

When navigating complex specialty drug approvals like Blenrep, having expert support can make the difference between approval and denial. Counterforce Health helps patients and clinicians turn insurance denials into successful appeals by identifying denial patterns and crafting evidence-backed responses that align with each payer's specific requirements.

From our advocates: "We've seen Cigna approve expensive cancer treatments after initially denying them when the appeal included comprehensive prior therapy documentation and clear medical necessity rationale. The key is often in how the clinical story is presented—connecting the dots between treatment failures and why this specific therapy is the appropriate next step."

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Insurance coverage decisions are made by your health plan and may vary based on your specific policy terms.

For additional help with insurance appeals in North Carolina, contact Smart NC at 1-855-408-1212 or visit the North Carolina Department of Insurance consumer resources.

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