Benlysta (belimumab) subcutaneous — Highmark

Initial criteria

• age ≥ 18 years
• Diagnosis of active lupus nephritis (ICD10: M32.14)
• Diagnosis confirmed by renal biopsy OR contraindication to renal biopsy AND laboratory findings specific to lupus nephritis (e.g., elevated serum creatinine, abnormal urine analysis [proteinuria ≥ 500 mg/day, hypoalbuminemia, hematuria, casts], decreased eGFR)
• Member will continue to receive concomitant standard of care for lupus nephritis which includes corticosteroids with one of the following: mycophenolate for induction followed by mycophenolate for maintenance OR cyclophosphamide for induction followed by azathioprine for maintenance

Reauthorization criteria

• Member is tolerating therapy AND has a therapeutic response defined as disease stability OR disease improvement
• Member will continue to receive concomitant standard of care for maintenance treatment of lupus nephritis with one of the following: mycophenolate OR azathioprine

Approval duration

12 months