CurrentMass General Brigham Health PlanPolicy N/A

Blenrep (belantamab mafodotin) — Prior Authorization and Coverage Criteria

This policy defines prior authorization, coverage criteria, and quantity/authorization limits for Blenrep (belantamab mafodotin) for treatment of relapsed or refractory multiple myeloma for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyBlenrep (belantamab mafodotin) — Prior Authorization and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization under the pharmacy benefit and document at least four prior therapies including an anti‑CD38, an immunomodulatory agent, and a proteasome inhibitor.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsapproval duration

>=4prior therapies

Anti-CD38, IMiD, PIrequired classes

Coverage Criteria for Blenrep (belantamab mafodotin)

Initial Therapy

Authorization may be granted when ALL of the following are met:

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Initial authorization requirements: Member has a diagnosis of relapsed or refractory multiple myeloma AND has received at least 4 prior therapies including at least one anti-CD38 monoclonal antibody (e.g., daratumumab), at least one immunomodulatory agent (e.g., lenalidomide, pomalidomide), and at least one proteasome inhibitor (e.g., bortezomib, ixazomib, carfilzomib)>=4 prior therapies

Documentation must be provided

Initial Therapy

Coverage for members new to the plan or initiating therapy:

Initial authorization: Member has relapsed or refractory multiple myeloma AND has received >=4 prior therapies including at least one anti-CD38 monoclonal antibody, one immunomodulatory agent, and one proteasome inhibitor; documentation provided>=4 prior therapies

Members currently receiving Blenrep may be reviewed for continuation unless product obtained as samples or via manufacturer's assistance

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Blenrep when obtained through the pharmacy benefit. Initial and continuation requests will be reviewed against the coverage criteria.

Benefit: Pharmacy benefit
Contact: All Plans Phone: 877-519-1908; Fax: 855-540-3693

Step Therapy

Step therapy / Quantity limit program applies

Step therapy and quantity limit program requirements apply as part of the pharmacy benefit for Blenrep.

Program Type: Quantity Limit
Benefit: Step Therapy

Documentation Required

Required documentation

Documentation must demonstrate the member has relapsed or refractory multiple myeloma and provide records of prior therapies.

Diagnosis documentation: relapsed or refractory multiple myeloma
Treatment records: detailed history of prior regimens including agents, dates, and responses

Denial Risk

Insufficient prior therapy — potential denial risk

Requests may be denied if the member has not received at least four prior therapies including the specified classes (an anti‑CD38 monoclonal antibody, an immunomodulatory agent, and a proteasome inhibitor).

Minimum prior therapies: ≥ 4 prior regimens
Required classes: at least one Anti‑CD38 monoclonal antibody (e.g., daratumumab); at least one immunomodulatory agent (e.g., lenalidomide, pomalidomide); at least one proteasome inhibitor (e.g., bortezomib, carfilzomib, ixazomib)

Program component	Program type / details
Step therapy	Step Therapy program applies under the pharmacy benefit
Quantity limit	Quantity Limit under the pharmacy benefit
Benefit	Pharmacy Benefit (Step Therapy); Medical Benefit specialty limitations noted

Quantity Limits and Authorization Duration

inv-13: Blenrep (belantamab mafodotin) — authorization duration 12 months

Authorization durationInitial approvals and reauthorizations will be for 12 months

Program typeQuantity Limit under the pharmacy benefit

Benefit/SettingPharmacy benefit with step therapy; specialty limitations noted under medical benefit

Effective date04/01/2021

Contact for prior authorizationPhone: 877-519-1908; Fax: 855-540-3693

Site of Care

Note

Infusion center / site‑of‑care — pharmacy benefit coverage

Blenrep is covered under the pharmacy benefit; infusion center/site‑of‑care considerations are subject to the plan's specialty limitations.

Program type: Pharmacy benefit with Step Therapy and Quantity Limit
Specialty limitations: noted as applicable in the benefit details

Background

Multiple myeloma is a malignancy of plasma cells that leads to accumulation of malignant plasma cells in the bone marrow. Blenrep (belantamab mafodotin) is an antibody–drug conjugate indicated for treatment of relapsed or refractory multiple myeloma in patients who have received multiple prior therapies. Coverage may be considered for members with a diagnosis of relapsed or refractory multiple myeloma who have received at least 4 prior therapies, including at least one anti‑CD38 monoclonal antibody (for example, daratumumab), one immunomodulatory agent (for example, lenalidomide or pomalidomide), and one proteasome inhibitor (for example, bortezomib, ixazomib, or carfilzomib).

Policy Summary

PayerMass General Brigham Health Plan

PolicyBlenrep (belantamab mafodotin) — Prior Authorization and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization under the pharmacy benefit and document at least four prior therapies including an anti‑CD38, an immunomodulatory agent, and a proteasome inhibitor.

SourceLink

On This Page

OpenPayer

Blenrep (belantamab mafodotin) — Prior Authorization and Coverage Criteria

Coverage Criteria for Blenrep (belantamab mafodotin)

Initial Therapy

Continuation of Therapy

Provider Actions and Requirements

Step Therapy / Quantity Limit Program

Quantity Limits and Authorization Duration

Site of Care

Definitions

Background