Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Belantamab mafodotin (Blenrep) may be considered medically necessary for use in individuals 18 years of age and older for the following:
Food and Drug Administration (FDA) Indications & National Comprehensive Cancer Network (NCCN) Recommendations
Multiple Myeloma
- As treatment of relapsed or refractory multiple myeloma in individuals who have received at least 4 prior therapies, including an anti-CD38 monoclonal antibody, a proteasome inhibitor, and an immunomodulatory agent; and
- Prescribed in accordance with all the requirements set forth by the Blenrep REMS prescribing program.
The use of belantamab mafodotin (Blenrep) for any other indication than listed above is considered experimental/investigational and therefore, not covered. The safety and/or efficacy cannot be established by review of the available published peer-reviewed literature.
Procedure Codes
