Benlysta (belimumab subcutaneous injection) — Cigna

Initial criteria

• Patient age ≥ 5 years; AND
• Patient has autoantibody-positive SLE defined as positive for ANA and/or anti-dsDNA antibody; AND
• Patient meets ONE of the following: (a) Medication used concurrently with at least one other standard therapy (e.g., antimalarial such as hydroxychloroquine, systemic corticosteroid such as prednisone, or immunosuppressant such as azathioprine, mycophenolate mofetil, methotrexate); OR (b) Patient intolerant to standard therapy due to significant toxicity, as determined by prescriber; AND
• Medication prescribed by or in consultation with a rheumatologist, clinical immunologist, nephrologist, neurologist, or dermatologist

Reauthorization criteria

• Patient meets ONE of the following: (a) Medication used concurrently with at least one other standard therapy (e.g., antimalarial such as hydroxychloroquine, systemic corticosteroid such as prednisone, or immunosuppressant such as azathioprine, mycophenolate mofetil, methotrexate); OR (b) Patient intolerant to standard therapy due to significant toxicity, as determined by prescriber; AND
• Medication prescribed by or in consultation with a rheumatologist, clinical immunologist, nephrologist, neurologist, or dermatologist; AND
• Patient has responded to Benlysta subcutaneous or intravenous, as determined by prescriber (e.g., reduction in flares, reduction in corticosteroid dose, decrease of anti-dsDNA titer, improvement in complement levels C3, C4, or improvement in specific organ dysfunction)

Approval duration

initial 4 months; continuation 1 year