Benlysta — Blue Cross Blue Shield of Montana

Initial criteria

• Patient has a diagnosis of active systemic lupus erythematosus (SLE) WITHOUT active lupus nephritis AND BOTH of the following: (1) currently treated with standard SLE therapy (corticosteroids, hydroxychloroquine, azathioprine, methotrexate, mycophenolate, cyclophosphamide); (2) will continue standard SLE therapy in combination with the requested agent OR
• Patient has a diagnosis of active lupus nephritis (LN) AND BOTH of the following: (1) currently treated with background immunosuppressive LN therapy (for Lupkynis: corticosteroids plus mycophenolate; for Benlysta: corticosteroids plus mycophenolate, azathioprine, or cyclophosphamide); (2) will continue background immunosuppressive LN therapy in combination with the requested agent
• Prescriber is a specialist in the area of the patient’s diagnosis (rheumatologist, nephrologist) or has consulted with a specialist
• If requested agent is Benlysta, ALL of the following: (A) patient does NOT have severe active CNS lupus; (B) EITHER (1) will NOT be used in combination with Lupkynis OR (2) patient has diagnosis of active LN AND has tried and had inadequate response to TWO standard therapy courses (e.g., corticosteroids + Benlysta + mycophenolate, azathioprine, or cyclophosphamide; corticosteroids + Lupkynis + mycophenolate) and will be using Benlysta in combination with Lupkynis + mycophenolate (medical records required)
• If requested agent is Lupkynis, BOTH of the following: (A) will NOT be used in combination with cyclophosphamide OR Saphnelo; (B) EITHER (1) will NOT be used in combination with Benlysta OR (2) patient has diagnosis of active LN AND has tried and had inadequate response to TWO standard therapy courses (e.g., corticosteroids + Benlysta + mycophenolate, azathioprine, or cyclophosphamide; corticosteroids + Lupkynis + mycophenolate) and will be using Lupkynis in combination with Benlysta + mycophenolate (medical records required)
• Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• Patient previously approved through plan's Prior Authorization process AND has had clinical benefit with the requested agent AND continues to meet indication and comedication criteria as per initial approval

Approval duration

12 months