CurrentCareSourcePolicy N/A

Blenrep (belantamab mafodotin) Utilization Management Medical Policy

Policy governing prior authorization and medical benefit coverage criteria for Blenrep (belantamab mafodotin) for treatment of relapsed/refractory multiple myeloma for CareSource members; applies to providers prescribing or consulting oncologists who manage Blenrep therapy.

Policy Summary

PayerCareSource

PolicyBlenrep (belantamab mafodotin) Utilization Management Medical Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateOct 16, 2024

Key ActionObtain prior authorization and approve for 1 year when the listed criteria and dosing are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yrinitial approval duration

2.5 mg/kgrecommended dose

>=4prior regimens req

NCCN v1.2025guideline cited

Coverage Criteria for Blenrep (belantamab mafodotin)

FDA‑Approved Indication (Multiple Myeloma)

Approve for 1 year if the patient meets ALL of the following (A, B, C, D, and E):

Initial Criteria: Patient is ≥ 18 years of age.

Initial Criteria: Patient is currently receiving Blenrep.

Initial Criteria: Patient has tried at least four systemic regimens.>= 4 prior systemic regimens

Initial Criteria: Among prior regimens the patient has received at least one proteasome inhibitor, at least one immunomodulatory drug, and at least one anti-CD38 monoclonal antibody.

Policy Summary

PayerCareSource

PolicyBlenrep (belantamab mafodotin) Utilization Management Medical Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateOct 16, 2024

Key ActionObtain prior authorization and approve for 1 year when the listed criteria and dosing are met.

SourceLink

On This Page

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Regimen	Indication / Eligibility	Dose and Schedule	Approval Duration
Blenrep (belantamab mafodotin) 2.5 mg/kg IV every 3 weeks
Relapsed or refractory multiple myeloma in adults who have received at least four prior systemic therapies, including at least one proteasome inhibitor, at least one immunomodulatory agent, and at least one anti‑CD38 monoclonal antibody; medication prescribed by or in consultation with an oncologist; patient is ≥ 18 years of age.
Approve up to 2.5 mg/kg administered intravenously; subsequent doses separated by at least 3 weeks.
Approve for 1 year when all criteria are met.

Provider Actions and Authorization Requirements

Prior Authorization

Prior authorization required; approve for 1 year when criteria met

Prior authorization is recommended for medical benefit coverage of Blenrep. Approval is recommended for patients who meet the listed Criteria and Dosing; when criteria are met, approve for 1 year. All approvals are provided for the duration noted; extended approvals are allowed if the patient continues to meet the Criteria and Dosing.

Approve up to 2.5 mg/kg IV with subsequent doses separated by at least 3 weeks.

Step Therapy

Prior systemic regimen requirement: ≥4 prior therapies including PI, IMiD, and anti‑CD38

Patient must have tried at least four prior systemic regimens before approval, including at least one proteasome inhibitor, at least one immunomodulatory drug, and at least one anti‑CD38 monoclonal antibody.

Examples of proteasome inhibitors: bortezomib (Velcade), carfilzomib (Kyprolis), ixazomib (Ninlaro).
Examples of immunomodulatory drugs: lenalidomide (Revlimid), pomalidomide (Pomalyst), thalidomide (Thalomid).
Examples of anti‑CD38 antibodies: daratumumab (intravenous or subcutaneous), isatuximab (Sarclisa).

Documentation Required

Specialist prescriber required; dose exceptions reviewed case‑by‑case

Blenrep must be prescribed by or in consultation with a physician who specializes in the condition treated (e.g., an oncologist). Requests for doses outside the established dosing documented in this policy will be considered case‑by‑case by a clinician.

Specialist involvement is required because of the specialized skills needed for evaluation, diagnosis, and monitoring of therapy.
Dose exceptions are reviewed by a Medical Director or Pharmacist on a case‑by‑case basis.

Denial Risk

Do not cover uses outside the listed authorization criteria

Coverage is not recommended for uses that are not listed in the Recommended Authorization Criteria; criteria will be updated as new published data become available.

Requests for indications or circumstances outside the specified criteria may be denied.

Covered Regimens and Administration

Covered Regimen	Coverage Status	Eligibility Requirements / Notes	Prescriber / Dose Exceptions
Blenrep 2.5 mg/kg IV every 3 weeks
covered with criteria
Patient ≥ 18 years; relapsed or refractory multiple myeloma after ≥ 4 prior systemic therapies including at least one proteasome inhibitor, one immunomodulatory drug, and one anti‑CD38 monoclonal antibody. NCCN lists Blenrep as useful in certain circumstances after at least four therapies and may be available via compassionate use.
Must be prescribed by or in consultation with an oncologist. Approve up to 2.5 mg/kg IV with subsequent doses separated by ≥ 3 weeks; requests for doses outside the established dosing considered case‑by‑case.

Background

Blenrep (belantamab mafodotin) is a B‑cell maturation antigen (BCMA)–directed antibody–drug conjugate indicated for treatment of relapsed or refractory multiple myeloma in adults who have received at least four prior therapies, including an anti‑CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent.

The policy requires prior authorization and limits approval to members who meet the specified criteria; when criteria are met, approval is typically issued for 1 year with dosing described as 2.5 mg/kg IV every 3 weeks and subsequent doses separated by at least 3 weeks.

OpenPayer

Blenrep (belantamab mafodotin) Utilization Management Medical Policy

Coverage Criteria for Blenrep (belantamab mafodotin)

Provider Actions and Authorization Requirements

Covered Regimens and Administration

Line of Therapy / Salvage Use

Definitions and Agent Name

Background