By Counterforce Health Team in Blenrep (belantamab mafodotin) —

How to Get Blenrep (Belantamab Mafodotin) Covered by Humana in Texas: PA Requirements, Appeals, and Approval Scripts

Answer Box: Getting Blenrep Covered by Humana in Texas

Current Status: Blenrep (belantamab mafodotin) was withdrawn from US markets in 2022 and is only available through clinical trials or expanded access programs. Humana typically denies coverage outside study settings.

If pursuing expanded access: (1) Submit prior authorization via Humana's provider portal with clinical trial documentation, (2) Request formulary exception for non-covered investigational use, (3) Appeal denial within 65 days using Texas external review rights. Success requires proving medical necessity and lack of alternatives through Texas Department of Insurance independent review.

Table of Contents

Plan Types & Coverage Implications

Humana operates multiple plan types in Texas, each with different coverage rules for specialty oncology drugs like Blenrep:

Medicare Advantage (Part C/D): Most common Humana coverage in Texas. Blenrep would fall under Part D (pharmacy benefit) or Part B (medical benefit) depending on administration setting. Medicare appeals process applies with 65-day filing deadlines.

Commercial Plans: Employer-sponsored or individual market plans follow Texas state insurance laws. These plans must offer internal appeals and external review through independent review organizations (IROs).

Medicaid Managed Care: Limited formulary access; requires Texas Health and Human Services fair hearing for denials.

Note: ERISA self-funded employer plans are exempt from Texas external review and follow federal appeal processes only.

Formulary Status & Alternatives

Current Coverage Status

Based on Humana's 2024-2025 Medicare formularies, Blenrep is not listed as a covered Part D drug. Any coverage would be:

  • Specialty tier (Tier 4/5) with high coinsurance
  • Prior authorization required
  • Limited to clinical trial settings

Alternative BCMA-Targeted Therapies

Drug Formulary Status PA Required Step Therapy
Teclistamab (Tecvayli) Specialty tier Yes After ≥4 prior therapies
Elranatamab (Elrexfio) Specialty tier Yes After anti-CD38 failure
Ide-cel CAR-T Medical benefit Yes Extensive PA criteria
Cilta-cel CAR-T Medical benefit Yes Extensive PA criteria

Source: Humana provider drug lists

Prior Authorization Requirements

Standard PA Process

Submission Methods:

  • Provider portal: Humana provider resources
  • Fax: 800-594-5309 (verify current number)
  • Phone: 866-488-5995 (providers) / 866-773-5959 (members)

Decision Timelines:

  • Standard: ≤7 days (Part D), ≤30 days (Part C pre-service)
  • Expedited: ≤72 hours when delay could seriously harm health

Medical Necessity Criteria

For investigational access to Blenrep, documentation must include:

Clinical Requirements:

  • Multiple myeloma diagnosis (ICD-10: C90.0-)
  • ≥4 prior therapy lines including:
    • Anti-CD38 antibody (daratumumab)
    • Proteasome inhibitor (bortezomib, carfilzomib)
    • Immunomodulatory drug (lenalidomide, pomalidomide)
  • Progressive disease on last therapy
  • ECOG performance status ≤2

Laboratory Requirements (within 30 days):

  • CBC with differential
  • Comprehensive metabolic panel
  • Ophthalmologic evaluation (for REMS monitoring)

Specialty Pharmacy Network

Preferred Partners

CenterWell Specialty Pharmacy (formerly Humana Specialty) is Humana's preferred specialty channel for high-cost oncology drugs. Benefits include:

  • Direct-to-patient shipping
  • Clinical support services
  • Prior authorization coordination

Alternative Options:

  • In-network specialty pharmacies via Humana pharmacy finder
  • Medically integrated dispensing (if provider pharmacy is contracted)
Important: Verify network status before dispensing to avoid claim denials or higher patient costs.

Cost-Share Structure

Specialty Tier Costs (Educational Only)

Medicare Part D: Typically 25-33% coinsurance until out-of-pocket threshold Commercial Plans: Varies by plan design; often $100-500+ per month

Financial Assistance Options:

Note: This is educational information only. Consult your plan documents for exact costs.

Submission Process

Step-by-Step: Fastest Path to Approval

  1. Verify Current Status (Patient/Clinic)
    • Check if Blenrep has returned to market via FDA drug database
    • Confirm expanded access program availability through GSK
  2. Gather Documentation (Clinic)
    • Complete treatment history
    • Recent imaging showing progression
    • Lab results within 30 days
    • Ophthalmology clearance
  3. Submit PA Request (Provider)
    • Use Humana provider portal
    • Include "investigational/compassionate use" designation
    • Request expedited review if clinically urgent
  4. Request Formulary Exception (If denied)
  5. File Appeal (Within 65 days)
    • Use appropriate appeal form based on plan type
    • Include detailed medical necessity letter

Appeals Playbook for Texas

Internal Appeals

Timeline: Must file within 65 days of denial notice

Required Documents:

  • Original denial letter
  • Humana appeal form
  • Updated medical necessity letter
  • Supporting clinical documentation

Texas External Review

Who Can Use: State-regulated plans (not ERISA or Medicare)

Process:

  1. Complete internal appeal first
  2. Request IRO review within 4 months of final denial
  3. Submit via Texas Department of Insurance

Timeline: 20 days standard, 5 days expedited

IRO Decision: Binding on insurer if overturned

Texas Resources:TDI Consumer Hotline: 1-800-252-3439Office of Public Insurance Counsel: 1-877-611-6742

Medicare Appeals (5-Level Process)

  1. Humana Reconsideration: 65 days to file
  2. Independent Review Entity: Automatic if upheld
  3. Administrative Law Judge: If $1,900+ threshold met
  4. Medicare Appeals Council: Next level review
  5. Federal District Court: Final appeal option

Source: Medicare appeals process

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
"Experimental/investigational" Prove medical necessity; cite FDA expanded access FDA correspondence, IRB approval
"Not medically necessary" Document failure of all alternatives Treatment timeline, progression notes
"Step therapy not met" Show contraindications to preferred agents Allergy records, intolerance documentation
"Quantity limits exceeded" Justify dosing per protocol Clinical trial protocol, dosing rationale

Clinician Corner: Medical Necessity Letter Checklist

Essential Elements:

  • Patient-specific clinical history
  • Detailed prior therapy outcomes
  • Rationale for Blenrep specifically
  • Guidelines supporting use (NCCN, investigational protocols)
  • Monitoring plan for ocular toxicity
  • Statement of urgency if applicable

Key Phrases: "All covered alternatives have failed or are contraindicated" (for formulary exceptions)

When to Escalate

Contact Texas Department of Insurance if:

  • Humana delays exceed regulatory timeframes
  • Appeal process violations occur
  • Pattern of inappropriate denials

File Complaint: TDI online portal or 1-800-252-3439

Seek Legal Help: Consider healthcare attorneys for high-value cases or systematic coverage denials

FAQ

Q: How long does Humana prior authorization take in Texas? A: Standard decisions within 7 days (Part D) or 30 days (Part C pre-service). Expedited reviews within 72 hours when delay could cause serious harm.

Q: Can I get Blenrep covered if it's not on formulary? A: Possibly through formulary exception, but requires proving all covered alternatives are ineffective or unsafe. Success rate is low for withdrawn drugs.

Q: What if Humana denies my expedited appeal request? A: You can file a grievance about the denial of expedited processing while continuing with standard appeal timeline.

Q: Does Texas external review apply to Medicare plans? A: No. Medicare plans follow federal appeals process through Independent Review Entities, not state IROs.

Q: How much will Blenrep cost if approved? A: Specialty tier drugs typically have 25-33% coinsurance for Medicare Part D. Exact costs vary by plan and are subject to annual out-of-pocket maximums.

Q: Can my doctor request a peer-to-peer review? A: Yes. Contact Humana provider services to schedule. This can be effective for complex oncology cases requiring clinical discussion.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance denials by creating evidence-backed appeals tailored to each payer's specific requirements. Our platform analyzes denial letters and payer policies to draft targeted rebuttals that address the exact criteria insurers use to make coverage decisions.

For complex cases like investigational drug access, having the right documentation and appeal strategy can make the difference between approval and denial. Counterforce Health's systematic approach ensures that every relevant clinical fact and policy argument is presented in the format most likely to succeed with each specific insurer.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and clinical circumstances. Always consult with healthcare providers and insurance representatives for case-specific guidance. For assistance with Texas insurance regulations, contact the Texas Department of Insurance at 1-800-252-3439.

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