Anthem Blue Cross (HMO, PPO, EPO) |
Benlysta (belimumab) |
Drugs for Pain and Fever : Arthritis and Pain Drugs |
- Available only through Specialty Pharmacy; For details on drug coverage click HERE; Dosing Limit: 10 mg/kg every 4 weeks;
- Step Therapy: Lupus Nephritis:
ST Single Generic
Systemic Lupus Erythematosus (SLE): ST Multiple Generics
- Prior Authorization: Lupus Nephritis:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Systemic Lupus Erythematosus (SLE): Documented Diagnosis: Yes
Duration: 1 year(s)
- Lupus Nephritis:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
Systemic Lupus Erythematosus (SLE): Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
SELENA-SLEDAI Score Required: N/A
Reauthorization SELENA-SLEDAI Score Required: N/A
Does Policy Include Excluded Indications: No
- PA Applies
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