Medical Policy

Effective Date:01/01/2012 Title:Benlysta (Belimumab)
Revision Date:02/01/2021 Document:BI336:00
CPT Code(s):J0490
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1. Benlysta (Belimumab) requires prior authorization.

2. Benlysta is used to treat a type of active systemic lupus erythematosus

   (SLE).

3. Benlysta is not covered for more serious types of lupus affecting the central nervous system.

Medical Statement

Benlysta (Belimumab) is considered medically necessary (for those plans in which it is covered) for members meeting the following conditions:

1)    Member is age 18 years or older (for SQ injection) or 5 years of age or older (for IV infusion)  AND

2)    Member has a diagnosis of active systemic lupus erythematosus (SLE) based on ACR criteria or active lupus nephritis AND

3)    Member has a positive autoantibody test (e.g. anti-nuclear antibody [ANA] greater than or equal to 1:80 and/or anti-double-stranded DNA [anti-dsDNA] greater than or equal to 30 IU/ml) AND

4)    Member has at least one of the following 3 baseline measurement scores: SELENA-SLEDAI, British Isles Lupus Assessment Group (BILAG) scores, or Physician’s Global Assessment (PGA) score AND

5)    Member has had an insufficient response to at least two (2) standard of care drug classes:

a.    Anti-malaria’s

b.    Corticosteroids

c.    Immunosuppresses (excluding intravenous cyclophosphamide)

Benlysta is not covered for individuals with active severe central nervous system (CNS) lupus, individuals who require high-dose prednisone (greater than 100mg/day) or use in combination with other biologics or intravenous cyclophosphamide.

Codes Used In This BI:

J0490    Belimumab Injection, 10mg

Limits
Intentially left empty
Reference

1.    Benlysta Product Information.  GlaxoSmithKline.  December 2020.

2.    Clinical Pharmacology Online.  “Belimumab”, retrieved 01-015-2021.

3.    Navarro SV, Guzman RM, Gallacher AE, et al. Efficacy and safety of Belimumab in patients with active systemic lupus erythematosus: a randomized, placebo-controlled, phase 3 trial. Lancet 2011;377:721-31

4.    Belimumab (Benlysta) for Systemic Lupus Erythematosus.  The Medical Letter.  Volume 53 (1366). June 13, 2011.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.