- Prior Authorization: Lupus Nephritis:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Systemic Lupus Erythematosus (SLE):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Lupus Nephritis:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Systemic Lupus Erythematosus (SLE):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Positive Autoantibody Test Required: Unspecified
SELENA-SLEDAI Score Required: N/A
Reauthorization SELENA-SLEDAI Score Required: N/A
Patient Exclusion Criteria Documented in Policy: Combination therapy with Lupkynis or Saphnelo
Reauthorization Requirements Documented in Policy: 2 of Adherence to product and standard of care therapy;Shows positive clinical response
Does Policy Include Excluded Indications: Yes
Supporting Documentation Requirements: Medical Tests
- Step Therapy: ST Single Generic
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