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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