Benlysta (belimumab) — CareFirst (Caremark)
active lupus nephritis
Initial criteria
- For systemic lupus erythematosus (SLE): Prior to initiating therapy, member is positive for autoantibodies relevant to SLE (e.g., ANA, anti-ds DNA, anti-Sm, antiphospholipid antibodies, complement proteins)
- For systemic lupus erythematosus (SLE): Member is receiving a standard treatment for SLE with any of the following (alone or in combination): glucocorticoids (e.g., prednisone, methylprednisolone, dexamethasone), antimalarials (e.g., hydroxychloroquine), or immunosuppressants (e.g., azathioprine, methotrexate, mycophenolate, cyclosporine, cyclophosphamide)
- For lupus nephritis: Prior to initiating therapy, member is positive for autoantibodies relevant to SLE or lupus nephritis was confirmed on kidney biopsy
- For lupus nephritis: Member is receiving a standard therapy regimen (e.g., cyclophosphamide, mycophenolate mofetil, azathioprine, glucocorticoids)
- Exclusion: Severe active central nervous system lupus or use in combination with other biologics not allowed
Reauthorization criteria
- Member has achieved or maintained a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms of the condition
Approval duration
12 months