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Coverage criteria policies

Belimumab (Benlysta®) - Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Belimumab (Benlysta) requires prior authorization from HealthPartners Pharmacy Administration.

Coverage

Belimumab (Benlysta) is considered medically necessary when the following criteria are met:

  1. Patient must have a diagnosis of systemic lupus erythematosus (SLE); and,
  2. Patient must have documentation that they are autoantibody positive, as evidenced by ANA (>1:80) and/or anti-dsDNA (>30IU/mL); and,
  3. Patient must have documented SLEDAI SCORE and Physicians Global Assessment prior to treatment initiation; and,
  4. Patient must be currently receiving standard therapy consisting of either; corticosteroids (e.g. prednisone, methylprednisolone), immunosuppresives (e.g. azathioprine, methotrexate, mycophenolate) or antimalarials (e.g. hydroxychloroquine), and have been on a stable dose for at least 3 months.

First approval will be limited to 3 months. Longer courses of therapy may be approved after documentation of clinical benefit from the patient's medical records maintained by the requesting practitioner verifying a reduction in the patient's signs and symptoms of SLE as evidence by medical progress notes

Limitations of Use: Benlysta is not covered if:

  1. Diagnosis of severe active lupus nephritis; or,
  2. Diagnosis of severe active central nervous system lupus; or,
  3. Concomitant use of other biologics; or,
  4. Concomitant use of intravenous cyclophosphamide; or,
  5. Active infection in last 60 days; or,
  6. Live vaccines within the last 30 days

Definitions

Systemic lupus erythematosus is a chronic inflammatory disease that occurs when the immune system attacks other cells and tissues in the body resulting in inflammation and damage. The heart, joints, skin, lungs, blood vessels, liver, kidneys and nervous system are commonly involved.

Benlysta (belimumab) is indicated for the treatment of adult patients with active, autoantibody-positive, systemic lupus erythematosus (SLE) who are receiving standard therapy.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS

Codes

Description

C9399

Unclassified drugs or biologicals (Hospital Outpatient Use ONLY)

J0490

Injection, belimumab, 10 mg

NDC

Codes

Description

49401008801

Benlysta 200 MG/ML SOAJ

49401008802

Benlysta 200 MG/ML SOAJ

49401008835

Benlysta 200 MG/ML SOAJ

49401008842

Benlysta 200 MG/ML SOSY

49401008847

Benlysta 200 MG/ML SOSY

49401010101

Benlysta 120mg SOLR

49401010201

Benlysta 400mg SOLR

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. https://mn.gov/dhs/partners-and-providers/policies-procedures/minnesota-health-care-programs/provider/types/rx/pa-criteria/benlysta.jsp

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Policy activity

  • 01/01/2017 - Date of origin
  • 10/01/2018 - Effective date
Review date
  • 08/2018
Revision date
  • 05/07/2018

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