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Lupkynis — Blue Cross Blue Shield of Kansas

active systemic lupus erythematosus (SLE)

Initial criteria

  • The patient will NOT be using the requested agent in combination with cyclophosphamide OR Saphnelo
  • ONE of the following:
  • 1. The patient will NOT be using the requested agent in combination with Benlysta OR
  • 2. BOTH of the following:
  • A. The patient has a diagnosis of active LN AND
  • B. The patient has tried and had an inadequate response to TWO standard therapy courses (e.g., corticosteroids and Benlysta plus mycophenolate, azathioprine, or cyclophosphamide; corticosteroids and Lupkynis plus mycophenolate) and will be using Lupkynis in combination with Benlysta plus mycophenolate (medical records required)
  • The patient does NOT have any FDA labeled contraindications to the requested agent
  • Prescriber is a specialist in the area of the patient’s diagnosis (e.g., rheumatologist, nephrologist), or has consulted with a specialist

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
  • The patient has had clinical benefit with the requested agent
  • ONE of the following:
  • A. The patient has a diagnosis of active SLE without active LN AND BOTH of the following:
  • 1. The patient is currently treated with standard SLE therapy (corticosteroids, hydroxychloroquine, azathioprine, methotrexate, mycophenolate, cyclophosphamide)
  • 2. The patient will continue standard SLE therapy in combination with the requested agent OR
  • B. The patient has a diagnosis of active LN AND BOTH of the following:
  • 1. The patient is currently treated with background immunosuppressive LN therapy (e.g., Lupkynis requests: corticosteroids plus mycophenolate; Benlysta requests: corticosteroids plus mycophenolate, azathioprine, or cyclophosphamide)
  • 2. The patient will continue background immunosuppressive LN therapy in combination with the requested agent OR
  • C. The patient has a diagnosis other than active SLE OR active LN
  • Prescriber is a specialist in the area of the patient’s diagnosis (e.g., rheumatologist, nephrologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
  • If the requested agent is Benlysta, then ALL of the following:
  • A. The patient does NOT have severe active CNS lupus AND
  • B. ONE of the following:
  • 1. The patient will NOT be using the requested agent in combination with Lupkynis OR
  • 2. BOTH of the following:
  • A. The patient has a diagnosis of active LN AND
  • B. The patient has tried and had an inadequate response to TWO standard therapy courses and will be using Benlysta in combination with Lupkynis plus mycophenolate (medical records required)
  • Requested agent will NOT be used in combination with other immunomodulatory agents (e.g., TNF inhibitors, JAK inhibitors, IL4 inhibitors) unless supported by clinical evidence and product labeling

Approval duration

12 months