By Counterforce Health Team in Blenrep (belantamab mafodotin) —

The Complete Requirements Checklist to Get Blenrep (Belantamab Mafodotin) Covered by UnitedHealthcare in North Carolina

Answer Box: Blenrep Coverage Status

Blenrep (belantamab mafodotin) has been withdrawn from the U.S. market by GSK. UnitedHealthcare will deny coverage requests for commercial Blenrep because it's no longer commercially available. However, patients may access Blenrep through GSK's compassionate use program if already enrolled in the REMS monitoring system. For new patients, focus on alternative BCMA-targeted therapies like CAR-T treatments (ide-cel, cilta-cel) or bispecific antibodies (teclistamab, elranatamab) that UnitedHealthcare does cover with proper prior authorization.

First step today: Contact your oncologist to discuss alternative BCMA-targeted treatments and initiate UnitedHealthcare prior authorization for covered options.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria for Alternative Treatments
  4. Coding Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Coordination
  8. After Submission Tracking
  9. Denial Prevention Tips
  10. Appeals Process in North Carolina
  11. Printable Checklist

Who Should Use This Checklist

This guide is designed for multiple myeloma patients and their healthcare teams in North Carolina who are:

  • Currently receiving Blenrep and need transition planning to alternative therapies
  • Seeking BCMA-targeted treatment options covered by UnitedHealthcare
  • Preparing prior authorization requests for CAR-T or bispecific antibody treatments
  • Navigating UnitedHealthcare's step therapy requirements for relapsed/refractory multiple myeloma

Expected outcome: With proper documentation and clinical justification, alternative BCMA-targeted therapies have high approval rates when FDA-approved indications are met and step therapy requirements are satisfied.

Member & Plan Basics

Verify Active Coverage

Before initiating any prior authorization, confirm these UnitedHealthcare plan details:

  • Member ID and group number from current insurance card
  • Plan type (Commercial, Medicare Advantage, or Medicaid managed care)
  • Specialty pharmacy benefits through OptumRx or other designated vendor
  • Annual deductible status and out-of-pocket maximums
  • Prior authorization requirements for specialty oncology medications
Tip: Call UnitedHealthcare member services at 1-866-889-8054 to verify specialty drug coverage and OptumRx pharmacy network requirements.

Authorization Requirements by Plan Type

Plan Type Prior Auth Required Typical Timeline Special Notes
Commercial Yes, for all BCMA-targeted therapies 5-15 business days Step therapy often applies
Medicare Advantage Yes, with additional CMS oversight 14-30 days Expedited available for urgent cases
Medicaid Managed Care Yes, state formulary restrictions 10-20 business days May require state Medicaid approval

Clinical Criteria for Alternative Treatments

Since Blenrep is not available, focus on these UnitedHealthcare-covered BCMA-targeted alternatives:

CAR-T Cell Therapies

Abecma (ide-cel) and Carvykti (cilta-cel) require:

  • Relapsed/refractory multiple myeloma after ≥4 prior therapies
  • Including an immunomodulatory agent, proteasome inhibitor, and anti-CD38 antibody
  • ECOG performance status 0-2
  • Adequate organ function per manufacturer specifications
  • Treatment at certified CAR-T center

Bispecific Antibodies

Tecvayli (teclistamab) and Elrexfio (elranatamab) criteria:

  • Relapsed/refractory multiple myeloma after ≥4 prior therapies (teclistamab) or ≥2 prior therapies (elranatamab)
  • Prior exposure to lenalidomide, proteasome inhibitor, and anti-CD38 antibody
  • Step-up dosing protocol capability at treatment facility
  • Cytokine release syndrome monitoring available
Note: UnitedHealthcare does not generally require step therapy for FDA-approved BCMA-targeted therapies when standard criteria are met.

Coding Requirements

ICD-10 Diagnosis Codes

Use the appropriate multiple myeloma code based on current disease status:

  • C90.00 – Multiple myeloma not having achieved remission
  • C90.02 – Multiple myeloma in relapse
  • C90.01 – Multiple myeloma in remission (for maintenance therapy)

HCPCS and Billing Codes

For CAR-T therapies, verify current codes with your billing department:

  • Q2041 – Axicabtagene ciloleucel (preliminary code)
  • Q2053 – Idecabtagene vicleucel (preliminary code)

For bispecific antibodies, use appropriate J-codes as assigned by CMS.

Important: Billing codes update frequently. Verify current HCPCS codes with CMS before submission.

Documentation Packet

Provider Note Elements

Your oncologist's clinical documentation must include:

Disease History:

  • Initial multiple myeloma diagnosis date and staging
  • Complete treatment history with specific agents, dates, and outcomes
  • Documentation of relapsed/refractory status with progression dates
  • Current disease burden assessment

Clinical Justification:

  • Why alternative BCMA-targeted therapy is medically necessary
  • Evidence of double-refractory or triple-refractory disease
  • Performance status and organ function assessments
  • Treatment goals and expected outcomes

Letter of Medical Necessity Components

A comprehensive medical necessity letter should address:

  1. FDA-approved indication for the requested therapy
  2. Prior therapy failures with specific agents and timeframes
  3. Contraindications to other available treatments
  4. Clinical guidelines support (NCCN, ASH, IMWG recommendations)
  5. Facility capabilities for safe administration and monitoring

Required Attachments

  • Complete treatment history documentation
  • Recent imaging studies showing disease progression
  • Laboratory values (CBC, comprehensive metabolic panel, LDH)
  • Bone marrow biopsy results confirming relapsed disease
  • Performance status assessment
  • Insurance authorization forms

Submission Process

OptumRx Prior Authorization

UnitedHealthcare routes specialty drug requests through OptumRx. Starting in 2025, OptumRx has automated prior authorization for many medications, reducing approval times to under 30 seconds for qualifying requests.

Submission Options:

  • Online: UnitedHealthcare Provider Portal (preferred method)
  • Phone: 1-800-711-4555 for provider support
  • Fax: Verify current fax number through provider portal

Required Form Fields

Common rejection reasons include incomplete:

  • Member demographic information
  • Prescriber NPI and DEA numbers
  • Specific drug name, strength, and NDC number
  • ICD-10 diagnosis codes
  • Clinical justification narrative
Tip: Use OptumRx's PreCheck Prior Authorization system when available to expedite standard requests.

Specialty Pharmacy Coordination

Preferred Vendor Network

UnitedHealthcare typically requires specialty medications through:

  • OptumRx Specialty Pharmacy (primary)
  • Accredo Health Group (secondary option)
  • BioPlus Specialty Pharmacy (select medications)

Transfer Process

  1. Prescription routing: Ensure prescriber sends to approved specialty pharmacy
  2. Benefits verification: Pharmacy confirms coverage and copay
  3. Patient enrollment: Complete specialty pharmacy intake process
  4. Shipment coordination: Arrange delivery timing with treatment schedule

After Submission Tracking

Confirmation and Status Checks

  • Record confirmation number from initial submission
  • Check status every 3-5 business days through provider portal
  • Document all communications with UnitedHealthcare and OptumRx
  • Monitor for additional information requests

Expected Timelines

Request Type Standard Timeline Expedited Timeline
Standard PA 5-15 business days 72 hours
CAR-T Authorization 10-20 business days 5-7 business days
Bispecific Antibodies 7-14 business days 48-72 hours

Denial Prevention Tips

Five Common Pitfalls and Solutions

  1. Insufficient prior therapy documentation
    • Fix: Provide detailed treatment history with dates, doses, and outcomes for each prior regimen
  2. Missing step therapy justification
    • Fix: Document medical necessity for bypassing preferred agents or explain why step therapy was unsuccessful
  3. Incomplete facility certification
    • Fix: Confirm treatment center is certified for CAR-T or has appropriate monitoring capabilities for bispecific antibodies
  4. Outdated clinical information
    • Fix: Include recent laboratory values, imaging, and disease assessment within 30 days of request
  5. Incorrect coding or billing information
    • Fix: Verify ICD-10 codes match current disease status and use appropriate HCPCS codes

Appeals Process in North Carolina

UnitedHealthcare Internal Appeals

If your request is denied, UnitedHealthcare offers a two-level internal appeals process:

Level 1 Appeal:

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for standard, 72 hours for expedited
  • Submission: Online portal, fax, or mail with complete documentation

Level 2 Appeal:

  • Automatic if Level 1 is denied
  • Reviewed by different medical personnel
  • May include external clinical expert review

Smart NC External Review

North Carolina residents can access independent external review through Smart NC after exhausting internal appeals:

Eligibility Requirements:

  • Completed both UnitedHealthcare internal appeal levels
  • State-regulated insurance plan
  • Denial based on medical necessity or experimental treatment determination
  • Filed within 120 days of final internal denial

Timeline:

  • Standard review: 45 calendar days
  • Expedited review: 4 business days for urgent cases

Success Rate: Approximately 32.4% of external reviews result in coverage approval.

Contact Smart NC: Call 1-855-408-1212 for free assistance with the external review process.

From our advocates: We've seen multiple myeloma patients successfully transition from Blenrep to CAR-T therapy through careful documentation of treatment history and clear clinical justification. The key is working closely with your oncologist to demonstrate why BCMA-targeted therapy remains the best option despite Blenrep's withdrawal. This composite experience reflects common patterns we observe, not guaranteed outcomes.

Counterforce Health specializes in helping patients navigate complex prior authorization and appeals processes for specialty medications. Our platform analyzes denial letters and insurance policies to create targeted, evidence-backed appeals that significantly improve approval rates for critical treatments like CAR-T and bispecific antibody therapies.

Printable Checklist

Before Starting:

  • Verify active UnitedHealthcare coverage and OptumRx benefits
  • Confirm treatment facility certification for chosen therapy
  • Gather complete medical records and treatment history

Documentation Required:

  • ICD-10 diagnosis code (C90.00, C90.01, or C90.02)
  • FDA-approved indication for requested therapy
  • Prior therapy documentation with dates and outcomes
  • Recent laboratory values and imaging studies
  • Medical necessity letter from oncologist
  • Facility certification documentation

Submission Process:

  • Submit through UnitedHealthcare Provider Portal
  • Record confirmation number and submission date
  • Monitor status every 3-5 business days
  • Respond promptly to information requests

If Denied:

  • Request peer-to-peer review within 5 business days
  • File Level 1 internal appeal within 180 days
  • Gather additional supporting documentation
  • Consider Smart NC external review if internal appeals fail

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage processes and should not be considered medical advice. Treatment decisions should always be made in consultation with qualified healthcare professionals. For specific questions about your UnitedHealthcare coverage or treatment options, contact your insurance plan directly or consult with your oncology team. North Carolina residents seeking assistance with insurance appeals can contact Smart NC at 1-855-408-1212 for free consumer advocacy services.

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