Benlysta (belimumab) — Medical Mutual

Initial criteria

• If the request is Belimumab for intravenous administration, the patient’s age is > 5 years OR if the request is Belimumab for subcutaneous administration, the patient’s age is > 18 years
• The patient has active, autoantibody-positive systemic lupus erythematosus despite > 6 weeks trial of conventional medical therapy
• SLE is active as documented by a SELENA-SLEDAI score ≥ 6 while on current treatment regimen
• Belimumab will be used in combination with conventional medical therapy (e.g., corticosteroids, antimalarials, or other immunosuppressants with or without nonsteroidal anti-inflammatories)
• Severe active central nervous system lupus erythematosus is not present
• Belimumab will not be used in combination with another biologic agent
• Site of care medical necessity is met

Reauthorization criteria

• Approve for an additional 12 months of therapy if the patient has responded to therapy as determined by the prescribing physician

Approval duration

initial 6 months, renewal 12 months