Benlysta (belimumab subcutaneous injection) — Cigna

Initial criteria

• Patient age ≥ 5 years; AND
• Diagnosis of lupus nephritis confirmed on biopsy (e.g., WHO class III, IV, or V); AND
• Medication used concurrently with an immunosuppressive regimen (e.g., azathioprine, cyclophosphamide, leflunomide, methotrexate, mycophenolate mofetil, and/or systemic corticosteroid); AND
• Prescribed by or in consultation with a nephrologist or rheumatologist

Reauthorization criteria

• Medication used concurrently with an immunosuppressive regimen (e.g., azathioprine, cyclophosphamide, leflunomide, methotrexate, mycophenolate mofetil, and/or systemic corticosteroid); AND
• Prescribed by or in consultation with a nephrologist or rheumatologist; AND
• Patient has responded to Benlysta subcutaneous or intravenous, as determined by the prescriber (e.g., improvement in organ dysfunction, reduction in flares, reduction in corticosteroid dose, decrease of anti-dsDNA titer, improvement in complement levels C3, C4)

Approval duration

initial 6 months; continuation 1 year