Lupkynis — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years; AND
• Diagnosis of lupus nephritis has been confirmed on biopsy (e.g., World Health Organization class III, IV, or V lupus nephritis); AND
• The medication is being used concurrently with an immunosuppressive regimen (e.g., mycophenolate mofetil or azathioprine with a systemic corticosteroid); AND
• Patient has an estimated glomerular filtration rate (eGFR) > 45 mL/min/m2; AND
• The medication is prescribed by or in consultation with a nephrologist or rheumatologist.

Reauthorization criteria

• Patient is age ≥ 18 years; AND
• The medication is being used concurrently with an immunosuppressive regimen (e.g., mycophenolate mofetil or azathioprine with a systemic corticosteroid); AND
• The medication is prescribed by or in consultation with a nephrologist or rheumatologist; AND
• Patient has responded to Lupkynis, 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; reauth 1 year