Belantamab mafodotin (Blenrep) - ARCHIVED

Policy ID: I-229-005

Section: Injections

Effective Date: December 01, 2020

Revised Date: May 16, 2023

Revision Effective Date: June 30, 2023

Last Reviewed: May 23, 2023

Applies To: Commercial and Medicaid Expansion

This policy has been Archived -Effective June 30, 2023. Click the Archive tab above for more information.

Policy ID: I-229-005

Section: Injections

Effective Date: December 01, 2020

Revised Date: May 16, 2023

Revision Effective Date: June 30, 2023

Last Reviewed: May 23, 2023

Archived Date: June 30, 2023

Applies To: Commercial and Medicaid Expansion

Description

Belantamab mafodotin- blmf (Blenrep) is an antibody-drug conjugate that targets B-cell maturation antigen (BCMA), a protein expressed on normal B lymphocytes and multiple myeloma cells.

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:

Multiple Myeloma

As treatment of relapsed or refractory multiple myeloma in individuals who have received at least four (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.

Compendia Sources

Belantamab mafodotin (Blenrep) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.

The use of belantamab mafodotin (Blenrep) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Codes

J9037

Note: Belantamab mafodotin (Blenrep) requires frequent ophthalmic exams at baseline, prior to each dose, and promptly for worsening symptoms.

This indication is approved under accelerated approval based on response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

Diagnosis Codes

C90.00

C90.02

C90.10

C90.12

C90.20

C90.22

C90.30

C90.32

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2020 Adopted new pre-certification policy

Internal Medical Policy Committee 1-19-2021- Effective January 01, 2021

Added new code C9069

Internal Medical Policy Committee 3-17-2021- Effective April 01, 2021

Removed code C9069; and
Added new code J9037

Internal Medical Policy Committee 3-23-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 1-26-2023 Effective March 01, 2023

Added statement 'Belantamab mafodotin (Blenrep) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.'
Removed diagnosis code Z85.72
Updated experimental/investigational statement

Internal Medical Policy Committee 5-23-2023 Archiving - Effective June 30, 2023

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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