Benlysta (belimumab) subcutaneous — Highmark

Initial criteria

• age ≥ 5 years
• Diagnosis of active SLE (ICD10: M32)
• Positive ANA titer (≥ 1:80) OR Anti-dsDNA ≥ 30 IU/mL
• Member will continue to receive concomitant standard of care for treatment of SLE which includes at least one of the following: corticosteroid (e.g., prednisone) OR antimalarial (e.g., hydroxychloroquine) OR immunosuppressant (e.g., azathioprine, mycophenolate, methotrexate)

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 treatment of SLE which includes at least one of the following: corticosteroid (e.g., prednisone) OR antimalarial (e.g., hydroxychloroquine) OR immunosuppressant (e.g., azathioprine, mycophenolate, methotrexate)

Approval duration

12 months