By Counterforce Health Team in Blenrep (belantamab mafodotin) —

Work With Your Doctor to Get Blenrep (Belantamab Mafodotin) Approved by UnitedHealthcare in Michigan: Complete Provider Collaboration Guide

Answer Box: Blenrep (belantamab mafodotin) is currently only available through GSK's compassionate use program after FDA withdrawal in 2022. UnitedHealthcare requires prior authorization for specialty oncology drugs, with 85% appeal success rates through peer-to-peer review. First step: Contact your oncologist to verify eligibility for compassionate use (4+ prior therapies including lenalidomide, proteasome inhibitor, and anti-CD38 antibody). Timeline: Standard PA takes 15 business days; appeals have 180 days from denial; Michigan external review within 127 days.

Table of Contents

  1. Set Your Goal: Understanding Blenrep Access Requirements
  2. Visit Preparation: Documenting Your Treatment Journey
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Peer-to-Peer Review
  6. After-Visit Documentation
  7. Respectful Persistence Strategy
  8. Appeals Process in Michigan
  9. FAQ

Set Your Goal: Understanding Blenrep Access Requirements

Current Status: Blenrep is not commercially available in the United States following GSK's voluntary withdrawal in November 2022. The drug is under FDA resubmission review with a PDUFA date of October 23, 2025.

Access Pathway: Currently available only through GSK's compassionate use program for eligible patients who meet specific criteria.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Age 18 years or older GSK compassionate use criteria
Diagnosis Relapsed/refractory multiple myeloma Medical records, pathology reports
Prior Therapies 4+ lines including lenalidomide, proteasome inhibitor, anti-CD38 Treatment history documentation
Facility Certification REMS-certified treatment center GSK provider enrollment: 855-209-9188
UnitedHealthcare PA Required for specialty oncology drugs OptumRx prior authorization

Your Partnership Goal: Work with your oncologist to demonstrate medical necessity and navigate both GSK's compassionate use enrollment and UnitedHealthcare's coverage determination process.

Visit Preparation: Documenting Your Treatment Journey

Before Your Appointment

Create a comprehensive treatment timeline that includes:

Treatment History Checklist:

  • Diagnosis date and staging information
  • Line 1 therapy: Drug names, start/stop dates, reason for discontinuation
  • Line 2 therapy: Include response duration and progression details
  • Line 3 therapy: Document any dose modifications or toxicities
  • Line 4+ therapies: Emphasize failed anti-CD38 therapy (daratumumab/isatuximab)

Functional Impact Notes:

  • Performance status changes during treatment
  • Quality of life impacts from disease progression
  • Ability to perform daily activities
  • Any hospitalizations related to disease progression
Tip: Bring a printed timeline to your appointment. This helps your oncologist quickly assess your eligibility for compassionate use and strengthens the medical necessity case.

Key Questions to Ask Your Doctor

  1. "Do I meet the criteria for GSK's Blenrep compassionate use program?"
  2. "Can you help me enroll in both the compassionate use program and submit a UnitedHealthcare prior authorization?"
  3. "What documentation will strengthen our medical necessity case?"

Building Your Evidence Kit

Laboratory and Imaging Documentation

Recent Test Results (within 30 days):

  • Complete blood count with differential
  • Comprehensive metabolic panel including creatinine
  • Serum protein electrophoresis and immunofixation
  • Beta-2 microglobulin and LDH levels
  • Recent imaging studies (CT, PET, MRI as appropriate)

Published Guidelines and References

Your oncologist should reference these in the medical necessity letter:

NCCN Guidelines: UnitedHealthcare recognizes NCCN recommendations as standard of care for oncology decisions. Categories 1, 2A, and 2B recommendations are typically covered.

FDA Guidance: Reference the original FDA approval criteria and the ongoing resubmission process to demonstrate established safety profile.

Peer-Reviewed Literature: Include studies supporting BCMA-targeted therapy in heavily pretreated multiple myeloma patients.

Treatment History Summary

Organize your medication history in this format:

Therapy Line Drugs Used Duration Best Response Reason for Discontinuation
1st Lenalidomide + dexamethasone 8 months Partial response Disease progression
2nd Bortezomib + cyclophosphamide + dex 6 months Stable disease Peripheral neuropathy
3rd Daratumumab + pomalidomide + dex 4 months Minimal response Disease progression
4th Carfilzomib + dexamethasone 3 months No response Disease progression

Medical Necessity Letter Structure

Essential Components

1. Clinical Problem Statement

  • Patient age, diagnosis date, and current disease status
  • Evidence of relapsed/refractory disease with imaging or lab confirmation
  • Performance status and functional limitations

2. Prior Treatment Documentation

  • Chronological list of all therapies with specific dates
  • Response to each treatment and reason for discontinuation
  • Emphasis on failure of standard therapies including anti-CD38 antibody

3. Clinical Rationale for Blenrep

  • BCMA targeting mechanism in heavily pretreated disease
  • Patient's exhaustion of standard therapeutic options
  • Potential for meaningful disease control based on clinical trial data

4. Risk Assessment

  • Consequences of treatment delay (disease progression, organ dysfunction)
  • Patient's limited remaining treatment options
  • Established safety profile from previous FDA approval

5. Supporting References Include citations to:

  • FDA prescribing information (when available)
  • NCCN guidelines for relapsed/refractory multiple myeloma
  • Published clinical trial data supporting efficacy
Clinician Corner: UnitedHealthcare overturns approximately 85% of appealed denials through peer-to-peer review. Request peer-to-peer immediately after any denial rather than waiting.

Supporting Peer-to-Peer Review

Preparing for the Medical Director Call

Your Role: Provide your oncologist with:

  • Your availability windows for urgent decisions
  • Concise summary of your treatment journey (1-2 paragraphs)
  • Specific functional limitations from disease progression

Scheduling Process: Your oncologist can request peer-to-peer review through the UnitedHealthcare Provider Portal or by calling 888-397-8129.

Key Discussion Points for Your Doctor

Clinical Urgency: Emphasize time-sensitive nature of multiple myeloma progression and limited remaining options.

Guideline Alignment: Reference NCCN recommendations for BCMA-targeted therapy in heavily pretreated patients.

Compassionate Use Context: Explain that Blenrep access is currently limited to compassionate use, demonstrating the exceptional medical need.

Counterforce Health specializes in helping patients, clinicians, and specialty pharmacies navigate complex prior authorization challenges by turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with each payer's specific requirements. For patients facing denials for innovative therapies like Blenrep, having expert support in crafting appeals can significantly improve approval odds.

After-Visit Documentation

What to Save

Portal Messages: Screenshot all communications between you and your care team about Blenrep access attempts.

Submission Confirmations: Keep records of:

  • GSK compassionate use program enrollment confirmation
  • UnitedHealthcare prior authorization submission receipt
  • Any fax confirmation numbers or portal submission IDs

Clinical Notes: Request copies of visit notes that document your treatment history and medical necessity for Blenrep.

Follow-Up Communication

Portal Messaging Template: "Hi Dr. [Name], thank you for submitting my Blenrep compassionate use enrollment and UnitedHealthcare prior authorization. Could you please let me know when you receive any updates? I'm also available for peer-to-peer review calls Monday-Friday 9am-5pm EST. Please keep me updated on next steps."

Respectful Persistence Strategy

Update Schedule

Week 1-2: Allow time for initial submission processing Week 3: Send polite inquiry about status via patient portal Week 4+: If no response, call clinic to request update

Escalation Approach

Internal Escalation:

  1. Start with your oncologist's nurse or clinic coordinator
  2. Request to speak with practice manager if no progress
  3. Ask about expedited review options for urgent cases

External Escalation: If internal appeals fail, prepare for Michigan DIFS external review process within 127 days of final denial.

Appeals Process in Michigan

UnitedHealthcare Internal Appeals

Timeline: Standard review takes up to 15 business days; expedited review available for urgent cases.

Submission: Through UnitedHealthcare member portal or by calling member services number on your insurance card.

Michigan External Review

Deadline: 127 days from final internal denial to file with Michigan Department of Insurance and Financial Services (DIFS).

Expedited Process: 72-hour review available for urgent cases with physician certification of medical necessity.

Contact: Michigan DIFS at 877-999-6442 for forms and guidance.

For complex appeals involving innovative therapies, Counterforce Health can help identify the specific denial basis and craft targeted rebuttals that align with UnitedHealthcare's own coverage policies and Michigan's appeal requirements.

FAQ

Q: How long does UnitedHealthcare prior authorization take for specialty oncology drugs? A: Standard review takes up to 15 business days, with expedited review available for urgent cases. Beginning in 2026, federal regulations will require decisions within 72 hours for urgent requests and 7 days for non-urgent requests.

Q: Can I get Blenrep covered if it's not on UnitedHealthcare's formulary? A: Yes, through medical exception processes. Since Blenrep is currently only available through compassionate use, coverage would require demonstrating exceptional medical necessity and exhaustion of formulary alternatives.

Q: What if I've failed therapies while living in another state? A: Treatment history from any state counts toward prior therapy requirements. Ensure your Michigan oncologist has complete records from previous providers.

Q: Does UnitedHealthcare require step therapy for multiple myeloma drugs? A: Yes, UnitedHealthcare typically requires progression through standard therapies first. However, exceptions are available with strong clinical documentation for patients who have contraindications or have failed required agents.

Q: Can I request expedited appeal in Michigan? A: Yes, Michigan offers 72-hour expedited external review for cases where delay would seriously jeopardize your health, but this requires physician certification and only applies to pre-service denials.

Q: What happens if GSK approves compassionate use but UnitedHealthcare denies coverage? A: You can pursue UnitedHealthcare's appeal process while exploring alternative funding through GSK patient assistance programs, manufacturer grants, or clinical trial enrollment for similar BCMA-targeted therapies.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and is not medical advice. Treatment decisions should always be made in consultation with your healthcare provider. For specific questions about your coverage, contact UnitedHealthcare member services directly. For appeals assistance in Michigan, contact DIFS at 877-999-6442.

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